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Learning Objective: To assess the visibility of the round window (RW) during cochlear implant (CI) surgery in pediatric patients through posterior tympanotomy versus trans canal route. Methodology: 80 prelingual pediatric patients prepared for CI were divided in randomized manner into two groups. Group (A): 40 patients underwent CI through classic mastiodectomy posterior tympanotomy approach (MPTA). Group (B): 40 patients underwent CI using endoscopic assisted combined approach technique (CAT) with limited posterior tympanotomy. Intraoperative evaluation of RW visibility through wide posterior tympanotomy after blue lining of the facial nerve (FN) and chorda tympani nerve (CTN) in group (A) patients and compared to RW visibility through trans canal using oto-microscopy and oto-endoscopy in group (B) patients. Results: Out of 40 patients in group (A), RW was fully visible in 20 patients through wide posterior tympanotomy, more than 50% of RW was visible in 10 patients, less than 50% of RW was visible in 8 patients and in 2 patients the RW could not bee seen with maximum surgical effort. For group (B), RW was fully visible in 24 patients through trans canal, more than 50% of RW was visible in 12 patients and in 4 patients less than 50% of RW was visible when using the oto-microscopy. In group (B) patients, the RW was fully visible in all patients when 00 endoscope was used. Conclusion: Endoscopic assisted CI surgery improves the RW visibility which is an important issue during CI surgery. [ABSTRACT FROM AUTHOR]