OBJECTIVES: Laparoscopic rectal cancer resection is a technically challenging surgery. Hand-assisted laparoscopic surgery(HALS) was common to avoid conversion to open surgery and potential intra-operative complications. This study aims to compare the clinical and economics outcomes of four surgical approaches for rectal cancer resection: HALS, non-HALS, convert-to-open surgery, and open surgery. METHODS: Rectal cancer patients underwent rectal resection from 01/2008-09/2015 in Premier Hospital Perspective® Database were included. HALS approach was defined by billing texts, and other surgical approaches were defined by ICD-9 procedure codes. Multivariate regression was used to examine the difference of postoperative complication rate, length of stay(LOS), operation-room(OR) time, hospitalization cost between HALS cases and patients with non-HALS, convert-to-open surgery, or open surgery, respectively. Further stratification analyses were performed by surgeon specialty or hospital teaching status. RESULTS: Among 25814 rectal cancer patients in study, 66.4% were open surgery, 7.59% were converted to open surgery, 17.35% were non-HALS, and 8.43% were HALS.  After adjustment, compared with convert-to-open cases, HALS cases had lower odds of post-operative complications(OR 0.77, 95%CI[0.66-0.94]), shorter OR time (-36.71 mins, 95%CI[-52.81, -20.60]) and lower hospitalization cost ($-1394.977, 95%CI[-2684.51, -105.44]). Compared to open surgery, HALS cases had lower odds of post-operative complications(OR 0.89, 95%CI [0.90-0.99]), and shorter LOS (-0.44 days, 95%CI[-0.75, -0.14]). However, compared to non-HALS, HALS had longer LOS (0.69 days, 95%CI [0.33, 1.04]) and higher direct cost($805.54, 95%CI[204.16, 1406.91]) with shorter OR time (-22.48mins, 95%CI[-37.19, -7.76]). Similar trending was observed when stratifying by surgeon specialty and teaching hospital status. The gap of direct cost between HALS and non-HALS MIS were bigger among cases in teaching hospitals and colorectal surgeons, compared with community hospitals and non-colorectal surgeon. CONCLUSIONS: HALS approach is associated with lower complications and shorter LOS compared to convert-to-open and open approach, yet is associated with longer LOS and hospitalization costs when compared to non-HALS in rectal cancer resection.