Interestingly, the initial series in the end of the twentieth century hardly entail detailed reports of the impact on fecal continence. The series of Aguilar and coworkers described an impairment of continence in about 10% of cases, whereas Schouten and coworkers report a significantly higher incidence of impaired conti­nence of 35% (Aguilar et al. 1985; Schouten et al. 1999). It is unclear exactly why patients who undergo advancement flap repair may encounter impaired continence. Even though the external anal sphincter is (supposedly) preserved in all patients, they frequently encounter minor impact on their fecal continence. Even though overt fecal incontinence is rare, minor impairment is a frequent finding, that should be discussed with the patient extensively and be part of shared decision-making. Aguilar attributes this impact on the inclusion of circular muscle fibers in the flap (Aguilar et al. 1985). Schouten and coworkers postulated that the use of the Parks retractor was a major contributing factor (Zimmerman et al. 2003a). This phenom­enon was also described by other authors (van Tets et al. 1997). It is difficult to draw meaningful conclusions on this subject; however, there are some indications in literature that the use of this retractor is a major contributing factor to fecal conti­nence impairment. It is rare for published results on flap repair to include detailed information on the impact on fecal continence. However, authors who describe the use of different retractors (such as Hill-Ferguson, Eisenhammer or Scott retractors) report an incidence of impaired continence varying between 0% and 12% (Ortiz et al. 2008; Hyman 1999; Perez et al. 2006), whereas authors who used the Parks retractor report an incidence of impaired continence varying between 28% and 40% (Schouten et al. 1999; van Koperen et al. 2008; Koehler et al. 2004). Moreover, in our own early work, we compared the use of the Parks retractor to the use of the Scott