Objective: The goal of this study was to disclose the appropriate surgical approaches to radically removing pediatric craniopharyngiomas with optimal hypothalamic protection. Methods: In 202 patients undergoing primary surgery from April 1997 to December 2002, eight approaches were used to remove craniopharyngiomas in the sellar region and the third ventricle. Among the eight approaches, the transcallosal-interseptal-interforniceal approach was used in 89 cases, the unilateral transfrontal interhemispheric approach in 68 cases, the pterional approach in 20 cases, and the other five approaches in 25 cases. Active preventive and therapeutic measurements of hypothalamic dysfunction were adopted pre- and postoperatively. Results: Of the 202 cases, 184 tumors were totally or nearly totally removed (91.1%); 89 cases were resected with the transcallosal-interseptal-interforniceal approach with a total and subtotal removal rate of 92.1%, and 68 cases were removed with the unilateral transfrontal interhemispheric approach with a total and subtotal removal rate of 95.6%. Two patients died (0.9%). The major postoperative complications included diabetes insipidus in 81.7% of the cases, permanent diabetes insipidus in 11.4%, electrolyte disorder in 74.8%, and seizures in 9.4%. The 5-year survival rate was 68.2%. Conclusions: Appropriate approaches with direct tumor exposure should be determined in order to remove the craniopharyngioma as much as possible, while at the same time carefully protecting the anteroinferolateral wall of the third ventricle (hypothalamus). Active measurements to manage blood sodium disorder and seizures could help to ensure the safety of the operation. Copyright © 2008 S. Karger AG.