Anastomotic complications occur after 5% to 20% of operations for rectosigmoid colon cancer. The intestinal perfusion status at the anastomotic site is an important modifiable risk factor, and surgeons should carefully evaluate and optimize the perfusion at the intended site of anastomosis. Indocyanine green (ICG) angiography is a simple noninvasive perfusion assessment modality. The use of ICG angiography is rapidly spreading in the field of colorectal surgery. However, there is debate on its contribution to reducing anastomotic complications. In this review, we discuss the clinical utility and the standardization of ICG angiography. ICG angiography can unequivocally reveal unfavorable perfusion zones and provide quantitative parameters to predict the risk of hypoperfusion-related anastomotic complications. Many studies have demonstrated the clinical utility of ICG angiography for reducing anastomotic complications. Recently, two multicenter randomized clinical trials reported that ICG angiography did not significantly reduce the incidence of anastomotic leakage. Most previous studies have been small-scale single-center studies, and there is no standardized ICG angiography protocol to date. Additionally, ICG angiography evaluations have mostly relied on surgeons’ subjective judgment. For these reasons, it is necessary to establish a standardized ICG angiography protocol and develop a quantitative analysis protocol for the objective assessment. In conclusion, ICG angiography could be useful for detecting poorly perfused colorectal segments to prevent anastomotic leakage after colorectal surgery. An optimized and standardized ICG angiography protocol should be established to improve the reliability of perfusion assessments. In the future, artificial intelligence-based quantitative analyses could be used to easily assess colonic perfusion status.
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