The transsylvian approach was introduced by MG Yaşargil to access the temporomesial structures and allow their selective resection. After splitting of the Sylvian fissure in microneurosurgical technique, access is gained to the temporal horn of the ventricle through an incision on the temporal side of the limen insulae. This exposes the mesial structures along their long axis without the need to transgress or lift the lateral temporal lobe. Pearls and pitfalls as well as a comparison with other approaches available regarding outcome and complications are presented in this chapter.