The purpose of this prospective cohort study was to compare multimodal pain management and pain perception after open vs. laparoscopic colorectal surgery within enhanced recovery care. Pain scores at rest and at mobilization were prospectively assessed in consecutive patients using Visual Analog Scales (VAS 0-10) and consumption of different analgesics was recorded daily until 96 hours postoperatively. Uni- and multivariate risk factors for pain peaks (≥ 4/10) were identified by logistic regression and compared between two propensity score matched groups (open vs. laparoscopic). 156 open and 176 laparoscopic procedures were included. Mean VAS scores were consistently < 3 until 96 hours at rest and at mobilization. Patients operated by laparoscopy experienced more pain peaks (≥ 4) within 24 hours (p < 0.05), while patients operated by open approach experienced more pain peaks (≥ 4) during mobilization at 72 hours (p < 0.05). Independent risk factors for insufficient pain control (≥ 4) within 24 hours from surgery were duration of the procedure (OR 3.37, 95%CI 2.03-5.59), emergency surgery (OR 3.01, 95%CI 1.72-5.31), wound infiltration (OR 3.23, 95%CI 0.97-10.70), age < 70 years (OR 2.03, 95% CI 1.18-3.48) and ASA I-II score (OR 2.06, 95% CI 1.19-3.56). The perioperative adding of lidocaine ± ketamine to opioids did not improve postoperative pain perception nor decrease morphine equivalents. In conclusion, overall pain scores were low after colorectal surgery. However, pain peaks remained a concern early after minimally invasive surgery and after epidural removal for open surgery. Multimodal strategies were not superior to opioids alone.