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To summarize the clinical efficacy, surgical key points, and advantageous mechanisms of complete endoscopic resection of pineal region lesions using the suboccipital supracerebellar approach. A retrospective analysis was performed on the clinical data of 8 patients with pineal region lesions who were treated by pure endoscopic suboccipital supracerebellar approach from July 2017 to June 2025. The surgery was performed with a lateral prone position and paramedian approach, and the lesions were exposed and resected through the natural suboccipital supracerebellar space under the assistance of pure endoscopy. All 8 patients achieved gross total resection (GTR) of the lesions under endoscopy, including 1 case of glioma, 1 case of germinoma, 3 cases of arachnoid cysts, 2 cases of metastatic tumors, and 1 case of cavernous hemangioma. Preoperatively, 6 patients were complicated with obstructive hydrocephalus, which was significantly relieved postoperatively; only 1 patient developed transient Parinaud syndrome, which recovered completely within 1 month after surgery. All patients were followed up for 6 months to 1 year. Imaging reexamination showed no recurrence of lesions, and the Karnofsky performance status (KPS) score was ≥80 in all patients, with a good prognosis. The pure endoscopic suboccipital supracerebellar approach, with its advantages of minimal invasiveness, close-range observation, and a clear field of view, can safely and effectively resect pineal region lesions while effectively relieving hydrocephalus and reducing surgical complications. It is one of the ideal surgical methods for the treatment of pineal region lesions, especially suitable for midline lesions extending to the posterior third ventricle.