Objective To describe a microsurgical alternative to endoscopic third ventriculocisternostomy. Methods Two children with shunt-dependent hydrocephalus and multiple shunt revisions were considered candidates for third ventriculocisternostomy (TVS). Because of slit ventricles, an endoscopic approach was not possible and, therefore, both patients received a microsurgical TVS by a supraorbital approach. Results In both cases, microsurgical TVS was successful and the patients became shunt free. Conclusion Microsurgical TVS by a supraorbital craniotomy is a viable alternative to endoscopic TVS in selected cases.