This chapter explains the key principles in the management of complex pediatric colorectal diagnoses. It provides case-based presentations, radiographic images, operative images with multiple choice questions to test knowledge. The chapter presents a case study of a 10-month-old female infant with an anorectal malformation. She has been managed with a divided sigmoid colostomy and mucous fistula. A cystoscopy and cloacagram are recommended in order to establish the length of the common channel, the length of the urethra (from the common channel to the bladder neck), and the distance the vagina needs to be mobilized to the perineum. If there is doubt about the feasibility of mobilizing the urethra and the vagina to the perineum, they would suggest that the surgeon elects to preserve the common channel as the urethra and minimizes disruption to its blood supply from the outset.