Posterior sagittal anorectoplasty was used for the first time in 1980 to treat anorectal malformations. This approach includes a wide exposure, through a midline posterior incision, to determine the limits of the sphincteric mechanism and to place the rectum within its limits. This approach has been used to treat children with anorectal malformations, who underwent conventional procedures that failed. The management of anorectal malformations with this approach rendered significantly better results in terms of bowel control. However, there is still a large number of patients suffering from fecal incontinence and for them a bowel management program was designed to improve their quality of life. The posterior sagittal approach was also used for the treatment of acquired conditions including tumors, post-trauma and postradiation fistulas, and other postoperative complications. A historic review of the posterior approach disclosed that Cripps, a British surgeon, published his experience with a posterior transsphincteric approach to the rectum nine years before Kraske, a German surgeon, whose name has been traditionally associated with the leadership in this approach. Kraske actually approached the rectum through a paramedian incision and never performed a real transsphincteric incision. An experimental study done in dogs by the author demonstrated that it is not harmful to divide the sphincteric mechanism. The posterior sagittal approach represents a useful alternative to treat many pelvic conditions and, therefore, it must be a part of the armamentarium of colorectal surgeons. Finally, a series of clinical experiences convinced the author that coordinated rectosigmoid motility is the most important single factor in fecal continence and, therefore, our efforts to help patients suffering from fecal incontinence must be aimed at the manipulation of bowel motility.