AbstractBackgroundNon‐restorative options for low rectal cancer not invading the sphincter includes low Hartmann's procedure (LH) and inter‐sphincteric abdominoperineal resection (ISAPR). There is currently little comparative data to differentiate these options.ObjectivesThe aim of this review was to assess the peri‐operative morbidity of LH, and then to compare it to that of ISAPR.Data SourcesAn up‐to‐date systematic review was performed on the available literature between 2000–2020 on PubMed, EMBASE, Medline, and Cochrane Library databases.Study SelectionAll studies reporting on non‐restorative surgeries for rectal cancer were analysed. Outcomes were firstly analysed between LH and non‐LH groups, with further sub‐analysis comparing the LH and ISAPR groups.Main outcome measureThe main outcome measures were the rates of pelvic sepsis, rates of overall post‐operative complication rates, oncological outcomes, and survival.ResultsA total of 12 observational studies were included. There were 3526 patients (61.1%) in the LH group, and 2238 patients (38.9%) in the non‐LH group, which included 461 patients who underwent ISAPR. The LH group had a higher rate of pelvic sepsis as compared to the non‐LH group (OR: 1.79, 95% CI: 1.39–2.29, P < 0.001). The difference is more marked in the sub‐analysis comparing LH and ISAPR alone (OR: 3.94, 95% CI: 1.88–7.84, P < 0.01) corresponding to a higher rate of unplanned re‐intervention. LH was associated with a higher rate of short‐term post‐operative mortality as compared to the non‐LH group.ConclusionISAPR is the preferred option for non‐restorative rectal surgery, with a more favourable peri‐operative morbidity and short‐term mortality profile as compared to LH.