Background <p>Anastomotic leakage (AL) remains a major complication following sphincter-preserving rectal cancer surgery. This study evaluates the association between intraoperative indocyanine green (ICG) fluorescence angiography and AL reduction.</p> Methods <p>A retrospective propensity score–matched cohort study including 318 consecutive patients undergoing minimally invasive anterior resection (AR), low anterior resection (LAR), or ultra-low anterior resection (ULAR). The Conventional Assessment Group (CAG) utilized white-light visualization including bowel color, mesenteric pulsation, and marginal bleeding. The ICG group underwent standardized intravenous ICG angiography (0.1–0.2 mg/kg) with near-infrared imaging prior to anastomosis. AL was defined according to ISREC criteria and confirmed clinically and/or radiologically.</p> Results <p>AL occurred in 1/92 (1.1%) in the ICG group versus 9/92 (9.8%) in CAG (<i>p</i> = 0.018). ICG prompted intraoperative revision in 9 (9.7%) patients, none of whom developed AL. On multivariate analysis, non-use of ICG (OR 8.9; <i>p</i> = 0.011), hypertension (OR 3.2; <i>p</i> = 0.015), and Left colic artery non-preservation (OR 2.5; <i>p</i> = 0.032) were independently associated with AL.</p> Conclusion <p>ICG perfusion assessment should be considered in minimally invasive rectal cancer surgery, particularly in high-risk anastomoses.</p>