The hippocampus, though small in size, is a highly complex brain structure critical for memory formation, spatial navigation, and the pathogenesis of mesial temporal lobe epilepsy (MTLE). MTLE involves the hippocampus and its surrounding regions and is the most frequent cause of focal epilepsies. Hippocampal sclerosis (HS), the leading lesion in MTLE, is multifactorial, involving febrile seizures, genetic predispositions, neuroinflammatory processes, and aberrant neurodevelopmental mechanisms. The hippocampus’s susceptibility to hyperexcitability and seizure development stems from its intrinsic neuronal properties and circuitry. Two main hypotheses—‘Dormant Basket Cell’ and ‘Mossy Fiber Sprouting’—propose mechanisms for HS-related epileptogenesis, though other factors are likely involved. The hippocampus’s involvement extends beyond focal extrahippocampal epilepsies to certain generalized epilepsies, such as juvenile myoclonic epilepsy. The International League Against Epilepsy (ILAE) classifies HS into types 1, 2, and 3 based on neuronal depletion and gliosis patterns, with clinical and prognostic implications. This classification aids in understanding variability in neuroimaging, electrophysiological findings, and postsurgical outcomes. Other causes of hippocampal epilepsies include tumors, vascular malformations, hematomas, brain injuries, genetic epilepsy, autoimmune encephalitis, and certain infections like the herpes simplex virus. The symptomatology of hippocampal seizures may encompass psychic, cognitive, emotional, autonomic, and sensory phenomena, reflecting the hippocampus’s involvement in multiple cognitive and physiological processes. Typically, when awareness is preserved, the ictal phase starts with an aura. The most reported and characteristic aura of hippocampal seizure is a visceral or ascending epigastric aura. An aura may remain isolated or be followed by impaired awareness, manifesting as motionless staring. Current treatment paradigms for hippocampal epilepsies include pharmacological approaches, surgical methods, and neuromodulation strategies. Innovative, less invasive surgical techniques for epilepsy and neuromodulation have been developed. These minimally invasive techniques are currently less effective than traditional surgeries but could, in the future, become more efficacious, thanks to a better understanding of the hippocampal region’s physiology.