Microvascular decompression has become the sole method for a curative treatment of primary hemifacial spasm. Finding the responsible conflicting artery is not always easy as its location can be deeply situated within the cerebellopontine/medullary fissure at the facial root exit zone. Sole or additional offending vessel(s) may be at the meatus of the internal auditory canal (5% of the cases). Identifying the compressive vessel(s) and performing decompression is in most cases possible without cerebellar retraction by classical microsurgical techniques. However, in a number of patients the neurovascular conflict may be hidden in spite of the direct illumination of the operative microscope. Therefore, assistance by endoscopy can be useful and contribute as a minimally invasive approach. The author reports his own experience in a series of 553 patients operated on over the past three decades. A total of 93.6% had complete relief of their spasm (11% after repeated surgery). Relief was delayed in 20.8% of these patients. Recurrence was rare (0.3%). There was no mortality and morbidity was low: deafness occurred in 0.6%. There was no permanent postoperative facial palsy. CSF leakage amounted to 1% in the last period of surgery. In conclusion, the author advocates combining the use of both the endoscopy for exploration and the microscope for decompression.