[Surgery of epilepsy in children: who, when, how, and why]

About 25% of epileptic patients continue to suffer from seizures despite adequate anticonvulsant therapy; they are pharmacoresistant. In these patients, the seizures may have a functional impact on their life and render them candidates to epilepsy surgery. Over the past 50 years, epilepsy surgery has been developed and popularized. In the last 15 years, it has been applied to the pediatric epilepsy population. Resistant epilepsy, often catastrophic in children, has important and bad consequences on the intellectual and social development, and may cause secondary brain damage. It is after a presurgical evaluation, aiming at a better comprehension of the epileptic problem as to its origin, propagation and functional impact on the child's psychomotor and social development, that a decision as to the surgical indication can be made. The neurosurgeon has different surgical therapeutic strategies, varying according to the type of epilepsy, the anatomical regions involved and the eventual post-operative functional impact. Thirty children have so far had the benefit of epilepsy surgery in the romand epilepsy surgical program. Multiple surgical techniques have been applied: lesionectomy, lobectomy, cortectomy, hemispherotomy, stereoelectroencephalography, subdural electrodes. The pathological substrate in paediatric epilepsy surgery is often related to cerebral developmental abnormalities. More than 75% of operated children have remained seizure free since surgery and many are on reduced medication. Subsequently to seizure cessation and reduction of medication, improvement in cognitive functions, behaviour and social integration can be witness. In some pharmacoresistant epilepsy of childhood, epilepsy surgery should not be considered the treatment of last resort, but rather the treatment of choice.