AIMS: Elective diverting ileostomy may reduce consequences of anastomotic leakage after laparoscopic total mesorectal excision (L-TME); however, its safety is debated because of morbidity related to stoma creation and closure. We aimed to investigate the impact of diverting ileostomy on clinical behavior of anastomotic leakage and complications related to stoma itself. MATERIAL OF THE STUDY: We retrospectively evaluated 150 L-TMEs with (Group 1, 100 patients) or without (Group 2, 50 patients) elective ileostomy for rectal cancer. RESULTS: Overall anastomotic fistula rate was 26% without significant differences between the two groups (28% in the Group 1 and 22% in the Group 2, respectively). In all the series, NAD was significantly associated with higher risk of postoperative complications (OR=2.14, p=0.02). In Group 2, NAD particularly increased the risk of anastomotic fistula (OR=6.6, p=0.014). Instead, patients of Group 1 showed higher odd of post-operative complications (OR: 3.8; CI 95%: 1.8483-8.0492; p = 0.0003) and notably 79 (79%) developed complications related to the ileostomy itself (hydroelectrolytic, metabolic and peristomal skin disorders). Moreover, thirty-two (32%) ileostomies were never reversed; among the reversed patients, 27 (39.7%) developed at least one postoperative complication and in 9 (33.3%) cases an urgent re-intervention was needed. DISCUSSION: Diverting ileostomy may mitigate clinical behavior of anastomotic leakage after L-TME. However, there is non-negligible morbidity of stoma creation and closure. CONCLUSION: Diverting ileostomy should be selectively considered in higher risk patients as those who received NAD.