Surgery for medically intractable childhood seizures originating in the opercular-insular cortex has only been undertaken in the last decade. While the need for SEEG interrogation and rates of post-operative seizure-freedom in children are comparable to adults, several important differences distinguish the pediatric experience. Most pediatric surgical candidates are pre-verbal or non-verbal and cannot describe subjective sensory or affective seizure manifestations. There is a higher representation of frontal lobe seizure semiology compared to adults, whereas ictal and inter-ictal electrographic discharges are typically more widespread throughout the cerebral hemisphere. Cortical malformations constitute the primary underlying pathological finding in the majority of pediatric cases. The recent surgical success in medically refractory children provides a compelling rationale to pursue further clinical studies and offer surgical candidacy in selected patients.