Many operative approaches to the sphenoid are possible. This is due to the anatomical characteristics of this bony structure, close to the facial cavities, covered by a meningeal lining and containing many vascular and nervous components. The choice of operative approach is guided by careful review of imaging data as well as limitations and risks of each approach. Sometimes, combined approaches in one or two stages are necessary. Only an adequate knowledge of each approach can allow the best surgical choice and limit the complications.