Surgical repair of old fourth-degree perineal lacerations

There are four basic surgical procedures for repair of old fourth-degree (complete) perineal lacerations: the layer closure, the Warren flap, Bowers' modification of the usual layer closure, and the Noble procedure. The Noble procedure avoids the deficiencies of the other procedures, and it is recommended as the best choice for this type of repair because it produces an intact rectal tube uncompromised by a suture line, is anatomically correct, is simple and easily mastered, and apparently has a near-zero failure rate.