An overall review of the authors’ anatomical perspective, approach, and experience with multichannel intracochlear implantation is presented. This report includes pertinent anatomical observations and experimental surgical procedures on fresh temporal bones. Although the scala tym- pani in the basal turn of the cochlea has an adequate space laterally for the insertion of electrodes, in the upper turns the adequate space is located medially. This is, in practice, the single-most limiting factor for an electrode, inserted via the round window, to reach the apical turns without damaging the basilar membrane. An experimental surgical procedure is described in which a second electrode is inserted in the middle turn via a mastoidotomy-tympanotomy approach and reaches a point near the apex. Studies of horizontal sections of human temporal bones include a review of potential structures that could be stimulated by the electrical currents generated by electrodes. The wall of the carotid artery, located at 750 μm from the basal turn at the level of the round window niche, is considered a potential structure to be affected by long-term stimulation. Anatomical principles and surgical considerations for the mastoidotomy-tympanotomy approach are described as an alternative to the facial recess approach. In the authors’ experience, this procedure is technically easier, eliminates the possibility of postauricular flap complications, provides a better angle for insertion of electrodes, requires shorter hospitalization, and permits faster recovery than the facial recess approach. The authors’ clinical approach, results, and observations are reviewed. Of note is a successful home-based rehabilitation program.