Objects: Fourth ventricle is conventionally accessed via resection of the part of the vermis for total excision of the tumors at the expense of significant morbidity. Numerous avenues have been identified to minimize the morbidity; some of which include transforaminal, subtonsillar, telovelar approaches, etc. These approaches are devised on the basis that accurate dissection along the natural avascular planes will avoid injury to the important structures in this area minimizing morbidity. We attempt to emphasize the technique of telovelar approach and the problems encountered while employing this technique for excision of large fourth ventricle tumors. Materials and methods: Fifteen patients with fourth ventricle tumors were operated during January to September 2005 at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. Fourteen of these cases were medulloblastomas, and one was ependymoma. All the patients were operated in prone oblique position via telovelar approach. Conclusion: Clear understanding of the normal anatomy will help in meticulous dissection and will result in reduced morbidity. Significant incidence of postoperative ataxia and mutism is seen with this approach in large tumors, and this can be avoided by staged dissection of the uvulotonsillar cleft. © Springer-Verlag 2007.