Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States and remains a major cause of significant morbidity and mortality. Current treatment options include medical management, catheter ablation, and surgical techniques, which have been improved over the past decades through surgical innovation and advancement in instrumentation. The gold standard of surgical treatment for AF is the Cox-maze procedure (CMP). First introduced clinically in 1987, the procedure used multiple incisions in the left and right atria to eliminate AF. This cut-and-sew technique was subsequently replaced by the CMP-IV with the advent of bipolar radiofrequency and cryoablation technology. The modern ablation devices have made the CMP technically faster and more amenable to minimally invasive approaches. This manuscript reviews the surgical technique of the CMP-IV through a median sternotomy approach.