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The anterior transabdominal approach could be performed via laparoscopic or open trans-abdominal/laparotomy, usually it 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 is considered as a relatively easy and safe technique. This approach allows to perform gently ligation of the stalk of the malformation without the need to decompress or remove the cyst, decreasing the risk of posterior infections. Other advantages obtained with this approach are 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 the patient to unnecessary surgical procedures. Imaging 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 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 and postoperative complete evaluation.