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# Discussion  Anterior sacral meningocele develops as a result of a defect characterized by focal erosion or hypogenesis of segments of the sacrum with herniation of the meningeal sac through the defect into the pelvis. It accounts They account  for about 5% of retrorectal masses, it is usually diagnosed in the second or third decades and are more prevalent in women.\cite{6828997} Presentation in elderly patients are less common, however it can occur as in the case described. The presentation of anterior sacral meningoceles can be subtle. Therefore, the patient’s medical history and physical examination findings are critical diagnostic tools. The patients may remain asymptomatic or present with nonspecific symptoms such as long-term constipation, urinary dysfunction, lower back pain, or perineal hypoalgesia.\cite{21977087}\cite{6470791} These symptoms may be due to direct compression of the herniated meningeal sac, spinal cord tethering, or sacral nerve root compression, diminished rectal and detrusor  tone, or numbness and paresthesia in the lower sacral 
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Surgical options consist primarily of either an anterior transabdominal or a posterior transsacral approaches. The main goal of surgery should be to safely disconnect the cyst from subarachnoid space to prevent further enlargement, thereby reducing the compression of nearby structures.   The anterior transabdominal approach could be performed via laparoscopic or open trans-abdominal/laparotomy, usuallyit  is not considered as the first option unless decompression and rapid removal of the cyst wall is required. Extreme caution must be taken when extensive resection of the cyst wall is performed since adherence to surrounding visceral structures can lead to complications such as fecal or vesical fistulas.\cite{16793455} Several reports have stressed the advantages of the posterior transsacral technique, this anatomical approach was first described by Adson et al in 1938 and even today it since there  is considered as a relatively easy and safe technique. This approach allows to perform gently ligation of the stalk of the malformation without the usually no  need to decompress or remove the cyst, decreasing the risk of cyst. Instead, treatment via a  posteriorinfections. Other advantages obtained with this  approachare preservation of the integrity of the nerve roots, spinal cord detethering and, if necessary, reconstruction of any dural defect by microsurgical techniques.  We present a case of a giant anterior sacral meningocele with some interesting nuances. Although the diagnosis sometimes can be very challenging, this phatology should always be kept in mind in order  to avoid erroneous diagnoses that may expose interrupt  the patient to unnecessary surgical procedures. Imaging fistula  is critical, but a carefully obtained medical history can reveal important clues. Surgery is generally advised, especially if there is compression on pelvic structures. Multiples surgical approaches are available, although the posterior approach remains the treatment of choice for most lesions, each approach must be carefully considered sufficient,  and the decision made on the basis of the specific surgical goals, on a case-by-case basis. Patients with these lesions should be cared for by a multidisciplinary team for further pre cyst will gradually  and postoperative complete evaluation. spontaneously resolve(citas).