Background: The Ancient Mesopotamian civilization, the earliest known, emerged in the fourth millennium BCE. While the advent of medicine is established, there is little understanding of surgery's origins. We sought to describe the characteristics and medical acumen of the surgeons of the first civilization.

Methods: Source documents and commentary on Mesopotamian medicine were systematically analyzed for evidence of surgery and physician descriptions.

Results: Early tablets reveal evidence of the incisional drainage of a scalp abscess and empyema, advanced wound care, fracture alignment, and possible caesarians without evidence of wound suturing, emergency procedures, trephination, or circumcision. While the asû and āšipu understood disease processes, strong evidence of an inextricable connection between spiritual and diagnostic/curative roles exists.

Conclusions: Mesopotamian physicians were diagnosticians and healers, approaching surgery as part of their holistic practice rather than a separate entity. Surgery was utilized as an endpoint to a careful process aided by objective evaluation and spiritual incantation.