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Background Minimally invasive approaches have been shown to reduce surgical site complications without compromising oncologic outcomes. Objective The primary aim of this study is to evaluate the rates of successful oncologic resection and postoperative outcomes among laparoscopic, open, and robotic approaches to rectal cancer resection. Design This is a multicenter, quasiexperimental cohort study using propensity score weighting. Settings Interventions were performed in hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. Patients Adult patients who underwent rectal cancer resection in 2016 were included. Main outcome measures The primary outcome was a composite variable indicating successful oncologic resection, defined as negative distal and radial margins with at least 12 lymph nodes evaluated. Results Among 1028 rectal cancer resections, 206 (20%) were approached laparoscopically, 192 (18.7%) were approached robotically, and 630 (61.3%) were open. After propensity score weighting, there were no significant sociodemographic or preoperative clinical differences among subcohorts. Compared to the laparoscopic approach, open and robotic approaches were associated with a decreased likelihood of successful oncologic resection (ORadj = 0.64; 95% CI, 0.43-0.94 and ORadj = 0.60; 95% CI, 0.37-0.97), and the open approach was associated with an increased likelihood of surgical site complications (ORadj = 2.53; 95% CI, 1.61-3.959). Compared to the laparoscopic approach, the open approach was associated with longer length of stay (6.8 vs 8.6 days, p = 0.002). Limitations This was an observational cohort study using a preexisting clinical data set. Despite adjusted propensity score methodology, unmeasured confounding may contribute to our findings. Conclusions Resections that were approached laparoscopically were more likely to achieve oncologic success. Minimally invasive approaches did not lengthen operative times and provided benefits of reduced surgical site complications and decreased postoperative length of stay. Further studies are needed to clarify clinical outcomes and factors that influence the choice of approach. See Video Abstract at http://links.lww.com/DCR/B70. RESULTADOS ONCOLOGICOS Y PERIOPERATORIOS DE LOS ABORDAJES LAPAROSCOPICOS, ABIERTOS Y ROBOTICOS PARA LA RESECCION DEL CANCER RECTAL: UN ESTUDIO DE COHORTE MULTICENTRICO Y PONDERADO DEL PUNTAJE DE PROPENSION: Se ha demostrado que los enfoques minimamente invasivos reducen las complicaciones del sitio quirurgico sin comprometer los resultados oncologicos.El objetivo principal de este estudio es evaluar las tasas de reseccion oncologica exitosa y los resultados postoperatorios entre los abordajes laparoscopico, abierto y robotico para la reseccion del cancer rectal.Este es un estudio de cohorte cuasi-experimental multicentrico que utiliza la ponderacion de puntaje de propension.Las intervenciones se realizaron en hospitales que participan en el Programa Nacional de Mejora de la Calidad Quirurgica del Colegio Americano de Cirujanos.Se incluyeron pacientes adultos que se sometieron a reseccion de cancer rectal en 2016.El resultado primario fue una variable compuesta que indicaba una reseccion oncologica exitosa, definida como margenes negativos distales y radiales con al menos 12 ganglios linfaticos evaluados.Entre 1,028 resecciones de cancer rectal, 206 (20%) fueron abordadas por via laparoscopica, 192 (18.7%) roboticamente y 630 (61.3%) abiertas. Despues de ponderar el puntaje de propension, no hubo diferencias sociodemograficas o clinicas preoperatorias significativas entre las subcohortes. En comparacion con el abordaje laparoscopico, los abordajes abiertos y roboticos se asociaron con una menor probabilidad de reseccion oncologica exitosa (ORadj = 0.64; IC 95%, 0.43-0.94 y ORadj = 0.60; IC 95%, 0.37-0.97), y el abordaje abierto se asocio con una mayor probabilidad de complicaciones del sitio quirurgico (ORadj = 2.53; IC 95%, 1.61-3.959). En comparacion con el abordaje laparoscopico, el abordaje abierto se asocio con una estadia mas prolongada (6.8 frente a 8.6 dias, p = 0.002).Este fue un estudio de cohorte observacional que utilizo un conjunto de datos clinicos preexistentes. A pesar de la metodologia de puntuacion de propension ajustada, la confusion no medida puede contribuir a nuestros hallazgos.Las resecciones que se abordaron por via laparoscopica tuvieron mas probabilidades de lograr el exito oncologico. Los enfoques minimamente invasivos no alargaron los tiempos quirurgicos y proporcionaron beneficios de la reduccion de las complicaciones del sitio quirurgico y la disminucion de la duracion de la estadia postoperatoria. Se necesitan mas estudios para aclarar los resultados clinicos y los factores que influyen en la eleccion del enfoque. Vea video resumen en http://links.lww.com/DCR/B70.