BACKGROUND: Short-term advantages to laparoscopic surgery are well described. This study compared medium- to long-term outcomes of a randomized clinical trial comparing laparoscopic and open colonic resection for cancer. METHODS: The case notes of patients included in the LAFA study (perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care) were reviewed 2-5 years after randomization for incisional hernia, adhesional small bowel obstruction (SBO), overall survival, cancer recurrence and quality of life (QoL). The laparoscopic and open groups were compared irrespective of fast-track or standard perioperative care. RESULTS: Data on incisional hernias, SBO, survival and recurrence were available for 399 of 400 patients: 208 laparoscopic and 191 open resections. These outcomes were corrected for duration of follow-up. Median follow-up was 3.4 (i.q.r. 2.6-4.4) years. Multivariable regression analysis showed that open resection was a risk factor for incisional hernia (odds ratio (OR) 2.44, 95 per cent confidence interval (c.i.) 1.12 to 5.26; P = 0.022) and SBO (OR 3.70, 1.07 to 12.50; P = 0.039). There were no differences in overall survival (hazard ratio 1.10, 95 per cent c.i. 0.67 to 1.80; P = 0.730) or in cumulative incidence of recurrence (P = 0.514) between the laparoscopic and open groups. There were no measured differences in QoL in 281 respondents (P > 0.350 for all scales). CONCLUSION: Laparoscopic colonic surgery led to fewer incisional hernia and adhesional SBO events. Registration number: NTR222 (http://www.trialregister.nl).