BACKGROUND: Perineal wound complications after extralevator abdominoperineal resection for cancer are common with no consensus on optimal reconstructive technique. We compared short- and long-term results of laparoscopic abdominoperineal resection with open surgery ± vertical rectus abdominis myocutaneous flap. METHODS: This is a single-institution retrospective observational study of 204 consecutive patients with advanced low rectal cancer who underwent extralevator abdominoperineal resection from January 2010 to August 2020. Main outcome measures were short-term results, wound complications, and incisional, parastomal, and perineal hernia rates. RESULTS: Fifty-five (27%) patients had a laparoscopic approach, 80 (39%) open, and 69 (33%) open + vertical rectus abdominis myocutaneous flap. The groups had similar median length of follow up (P = .75). Patients' age and radiation, intraoperative and postoperative complications, mortality, and readmission rates were similar among the 3 groups. Perineal wound infection and dehiscence rates were not influenced by surgical approach. Laparoscopy resulted in higher perineal (7.3 vs 2.5 vs 0%; P = .047) and parastomal (23.6 vs 13.8 vs 5.8%; P = .016) hernia rates than did open or open + vertical rectus abdominis myocutaneous flap. Patients who underwent an open approach had a higher body mass index and rate of prior surgeries and preoperative ostomies. Laparoscopic and open approaches had significantly shorter operative times (300 vs 303 vs 404 minutes, respectively; P < .001) and shorter length of stay (7.6 vs 10.8 vs 11.12, respectively; P = .006) compared to open with a flap approach. CONCLUSION: Open and open + vertical rectus abdominis myocutaneous flap approaches for reconstruction after abdominoperineal resection had lower parastomal and perineal hernias rates but similar postoperative morbidity as did the laparoscopic approach.