Middle ear implant (MEI) was developed over time with the idea that they would overcome some of the limitations encountered by conventional hearing aids. These concerns have included but are not limited to sub-optimal acoustics, occlusion effect, chronic ear discharge due to chronic otitis media or mastoid cavities and inability to tolerate healing aids due to chronic otitis externa. The Vibrant Sound Bridge (VSB), is a semi-implantable device designed by Geoffrey Ball. It was originally designed to be coupled to the incus long process in patients with sensorineural hearing loss. Of all the active middle ear implants, the maximum experience worldwide has probably been with the Vibrant Sound Bridge (VSB). For this reason, the surgical considerations for the vibrant sound bridge middle ear implant will be discussed in detail in this chapter.