Anorectal malformations have been treated in a rather empirical way for many years; most surgeons performed a perineal anoplasty without a colostomy for low malformations. A colostomy was performed during the newborn period, followed by an abdominoperineal pullthrough for the treatment of those defects in which the rectum was found to be very high in the pelvis. All those pullthroughs were done in a very blind manner. 1,3 The results, in terms of bowel control, were very bad. In 1953, Douglas Stephens proposed an initial sacral approach sometimes followed by an abdominal operation. 4 His specific recommendation was to operate on these patients through a sacral approach and create a tunnel immediately behind the urogenital tract, then to separate the rectum from the urogenital tract and pull the rectum through as close as possible to the urethra or vagina to preserve the puborectalis sling. In September 1980, this author and Dr. Peter de Vries performed the first posterior sagittal approach, which allowed a direct exposure and visualization of this important anatomic area. 5,6 This new approach also provided the unique opportunity to correlate the external appearance of the perineum with the operative findings and, subsequently, with the clinical results. The results with this approach, in terms of bowel control, are far superior to those obtained with previous types of operations.