Direct sphincter trauma or neuropathic injuries from vaginal deliveries are the principal causative factors in the development of fecal incontinence in women less than 40 years old. Additional reasons for fecal incontinence include conditions that predispose the patient to diarrhea, neurologic conditions, chronic medical conditions such as diabetes, obesity, and COPD, iatrogenic injuries from anorectal operations, trauma, and anatomic conditions including rectal prolapse and congenital abnormalities. Treatment options for the incontinent patient include nonoperative interventions such as medications to improve stool consistency and biofeedback, procedures including injection of bulking agents and controlled delivery of radio frequency energy (Secca), and operative interventions including anal sphincteroplasty, sacral nerve stimulation (SNS), artificial bowel sphincter, posterior anal repair, dynamic graciloplasty, transobturator posterior anal sling (TOPAS) procedure, and Fenix™ or magnetic sphincter augmentation. Anal sphincteroplasty has been the preferred surgical treatment for the symptomatic patient with an anatomically disrupted external anal sphincter (EAS) muscle. Short-term results report improved bowel continence as high as 90% with decreasing continence (0–73%) in long-term follow-up studies. Anal sphincteroplasty does not require expensive devices or postoperative maintenance necessary with implantable devices and remains an important treatment modality to treat patients with fecal incontinence with a disrupted anal sphincter who do not want an implantable device or who live in communities in which postoperative maintenance is not available. Sphincteroplasty can also be performed in conjunction with other pelvic organ prolapse and urinary incontinence procedures without additional morbidity and potentially some improvement in continence. The complications associated with anal sphincteroplasty are minor and include wound complications, UTI, chronic pain or discomfort, and recurrence of fecal incontinence. Major complications are rare. Complications can be avoided by thorough patient evaluation, including optimization of bowel habits, assessment of tissue quality, management of comorbidities, appropriate counseling of patients as to expected outcomes, physical exam, including anal physiologic testing in appropriate cases, and appropriate perioperative care. Additionally, anticipating potential complications and prompt management of a complication, should it occur, can minimize the overall impact on the patient.