Since its clinical introduction 40 years ago, cochlear implantation surgery has continued to evolve. Although the standard mastoidectomy with posterior tympanotomy has not changed, recent refinements have focused on minimal incisions and implantation techniques designed to preserve hearing. Evidence shows that smaller incisions with modest manipulation of soft tissue do not affect postoperative healing outcomes. There has been a trend advocating "soft surgical" techniques in an attempt to preserve the cochlear sensory epithelium. However, the literature is inconclusive as to the outcomes of "soft surgical" over standard techniques for hearing preservation, including round window insertion and the use of adjuvants with insertion. Cochlear implantation remains an important therapeutic option for hearing loss, with new techniques and implant designs offering prospects for better outcomes using less invasive techniques.