We thank Dr. Baldari and colleagues for having commented upon our article on fluorescence angiography during transanal total mesorectal excision. We agree with their statement that “anastomotic leakage is a multifactorial complication”. Towards that end, one of the senior authors (SD Wexner) routinely mobilizes the splenic flexure and both senior authors (SD Wexner and AM Lacy) routinely perform high ligation of the inferior mesenteric artery and vein. Both senior authors routinely intracorporeally divide the mesentery from the pedicle of the inferior mesenteric vessels to the sigmoid descending colonic junction. In addition, both senior authors routinely air test the anastomosis and, in the case of a hand-sewn anastomosis perform a “reverse” leak test (1). Direct endoscopic visualization of the anastomosis is always a part of every operation. We also agree with the statement of Baldari and coauthors that “adequate blood supply is one of the main factors in anastomotic healing”. For that reason, both senior authors routinely employ indocyanine green fluorescence angiography for all high risk left sided colorectal and coloanal anastomoses (2-5).
Conflicts of Interest: The author has no conflicts of interest to declare.
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Cite this article as: Wexner SD. Fluorescence angiography during transanal total mesorectal excision: steps to a safer anastomosis. Ann Laparosc Endosc Surg 2019;4:46.