This video demonstrates a transperineal repair of anal atresia with perineal fistula in a middle-aged woman. The perineal fistula, in the form of a rectal mucosal cuff, is dissected from the posterior vaginal wall. The full-thickness rectal wall proximal to this point is repositioned within the posteriorly based sphincter complex by means of an overlapping sphincteroplasty. An anterior levatoroplasty is also performed.