This chapter examines the advances in functional brain imaging, neuroanaesthesia and neurosurgical technique that have contributed to the utility and efficacy of awake surgery for medically refractory temporal lobe epilepsy. Awake surgery with intraoperative functional stimulation mapping is surprisingly well tolerated by most patients. During the early years, all patients were operated awake; however, over the past 15 years only patients requiring cortical stimulation mapping (CSM) of eloquent cortex during surgery have been operated with awake techniques. Extensive patient preparation for the procedure, experienced operative teams including a specialized nurse practitioner, a neurophysiology technical staff and improved anaesthetic techniques all have contributed to the success of these procedures.Authors‘ practice is to pursue a total hippocampal removal, assuming that their preoperative multivariate analysis of neuropsychological, imaging and electrographic parameters predicts a favourable outcome with regard to verbal memory.