Purpose <p>The textbook outcome has emerged as a valuable metric for quality assessment in oncological surgery. However, its application and impact within randomized controlled trials involving patients with low rectal cancer remain underexplored. This study aimed to investigate the incidence and predictors of textbook outcome in patients with low rectal cancer undergoing laparoscopic or open resection.</p> Methods <p>This post-hoc analysis included patients from the prospective, multicentric LASRE trial with clinically staged I-III rectal cancer located within 5&#xa0;cm of the dentate line, tumor diameter &lt; 6&#xa0;cm, and undergoing radical laparoscopic or open resection. A total of 914 patients were analyzed.</p> Results <p>A textbook outcome was achieved in 74.9% of patients, with a higher rate in the laparoscopic group (76.7%) than in the open group (71.2%, <i>P</i> = 0.07). Multivariate analysis identified independent predictors of textbook outcome&#xa0;failure, including BMI &gt; 24&#xa0;kg/m², surgical type (abdominoperineal resection), and operative time &gt; 200&#xa0;min. Achievement of a textbook outcome was associated with improved disease-free survival (DFS).</p> Conclusion <p>Achieving a textbook outcome is significantly associated with improved DFS in patients with low rectal cancer. These findings highlight the importance of optimizing perioperative and intraoperative care to enhance surgical outcomes, particularly within the context of randomized controlled trials.</p> Trial registration <p>ClinicalTrials.gov Identifier: <a href="https://clinicaltrials.gov/study/NCT01899547">https://clinicaltrials.gov/study/NCT01899547</a>.</p>