Background <p>Myocardial infarction and ischemic stroke are common causes of morbidity after major cancer surgery. Understanding the risks associated with both open and laparoscopic surgery is crucial in reducing postoperative morbidity and mortality.</p> Methods <p>This nationwide cohort study included patients who underwent major cancer surgery in the pelvis from 2000 to 2015. The primary outcome was the incidence of myocardial infarction and ischemic stroke within 90 days postoperatively. Adjusted odds ratios (OR) were estimated using logistic regression adjusted for propensity score and risks by regression standardization.</p> Results <p>A total of 22,619 patients operated with laparoscopic and 70,896 patients operated with open approach were included in the analysis. The crude 90-day cumulative risks of myocardial infarction and ischemic stroke were 0.66% and 0.48%, respectively. Laparoscopic surgery was associated with lower odds of myocardial infarction within 30 days (OR 0.39, 95% CI 0.23–0.62) and 90 days (OR 0.57, 95% CI 0.41–0.81) compared to open surgery. Similarly, an association was observed for ischemic stroke (OR 0.67, 95% CI 0.38–1.05 at 30 days; OR 0.69, 95% CI 0.45–0.80 at 90 days).</p> Conclusions <p>Laparoscopic surgery is associated with reduced postoperative risk of myocardial infarction and ischemic stroke compared to open surgery in the treatment of pelvic cancers. These findings favor the broader adoption of minimally invasive techniques in clinical practice.</p>