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The anterior transabdominal approach may be performed via laparoscopic or open trans-abdominal/laparotomy, usually it is not considered as the first surgical 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. (citas) technique.\cite{14576957}  This anatomical approach was first described by Adson et al. in 1938 and even today it is considered as a relatively easy and safe technique. This approach allows ligation of the stalk of the ASM without the need to decompress or remove the cyst, decreasing the risk of further infections. Other advantages of this approach are control of the nerve roots, filum terminale and dura matter. 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  the patient to unnecessary invasive procedures. Imaging is critical, but a careful obtained medical history can reveal important clues. Surgery is generally advised, especially if there is compression on pelvic structures. Multiple surgical  approaches are available. Nonetheless, the posterior approach remains  the treatment of choice for most lesions. Each approach  must be carefully analyzed and the choise choice  should be made on the basis of the specific surgical goals pretended for each case.