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BACKGROUND Omentoplasty is a commonly performed procedure after abdominoperineal resection for rectal cancer, but its effectiveness to reduce pelviperineal complications is not firmly established. OBJECTIVE To assess the impact of omentoplasty on short-term pelviperineal complications and postoperative outcomes following long-course (chemo)radiotherapy and abdominoperineal resection in patients with locally advanced and locally recurrent rectal cancer. DESIGN Retrospective cohort study. SETTINGS Single center. PATIENTS All patients with locally advanced and locally recurrent rectal cancer undergoing abdominoperineal resection after neoadjuvant (chemo)radiation in a tertiary referral center between 2008 and 2020 were retrospectively reviewed. MAIN OUTCOME MEASURES Multivariable logistic and linear regression analyses were performed to examine the association between omentoplasty and pelviperineal complications (e.g., perineal wound problems and pelvic abscesses), duration of nasogastric tube drainage and length of hospital stay. RESULTS A total of 305 patients were analysed of which 245 underwent omentoplasty (80%). Pelviperineal complications occurred in 151 patients (50%) overall, and in 125 (51%) and 26 (43%) of patients with or without omentoplasty, respectively. Independent predictors of pelviperineal complications in multivariable analyses were smoking (OR 2.68, 95% CI 1.46 - 4.94) and high BMI (OR 1.68, 95% CI 1.00 - 2.83), but not omentoplasty (OR 1.36, 95% CI 0.77-2.40). Mean duration of nasogastric tube drainage was longer after omentoplasty (6 vs. 4 days) with a significant association in multivariable analysis (β-coefficient 1.97, 95% CI 0.35-3.59). Patients undergoing omentoplasty had a significantly longer hospital stay (14 vs. 10 days), and omentoplasty remained associated with a prolonged hospital stay after adjusting for confounding (β-coefficient 3.05, 95% CI 0.05-5.74). LIMITATIONS Retrospective design. CONCLUSION Omentoplasty was not associated with a reduced risk of the occurrence of short-term pelviperineal complications after abdominoperineal resection in patients undergoing long-course (chemo)radiotherapy. Furthermore, in patients undergoing omentoplasty a prolonged duration of nasogastric tube drainage and hospital stay was observed. See Video Abstract at http://links.lww.com/DCR/C124.