Anastomotic leakage (AL) is the most feared complication in colorectal surgery and preventing this serious morbidity is a primary goal. Although the etiology of AL is multifactorial, three categories of risk factors can be identified. The first group includes “patient-related factors” like advanced age, male gender, obesity, concomitant diseases, etc.
The second group is directly associated with the underlying pathology e.g., low rectal cancer and prior radiation, while the third group is surgery-related. The third group may include all perioperative aspects from preoperative preparation, surgical technique, postoperative management, etc and is therefore not limited to the expertise of the operating surgeon alone.
Studying bowel perfusion objectively prior to creating an anastomosis and ensuring viable bowel perfusion is crucial in reducing the risk of AL. However, it must be clearly stated that, if sub-optimal perfusion was the only culprit, the rate of AL would be zero in all ICG cohorts. This emphasizes the multifactorial cause of AL. Nevertheless, real-time perfusion studies using ICG can be seen as an additional means of increasing patient’s safety in colorectal surgery.