BACKGROUND: Although many surgical strategies have been used to reduce the anastomotic leak (AL) rate after laparoscopic rectal cancer surgery, limited data are available on the risk factors for AL and the effective strategy to reduce AL. METHODS: The present study enrolled 736 consecutive patients who underwent laparoscopic resection without a diverting stoma for rectal adenocarcinoma. A nomogram was constructed to predict AL. Based on the nomogram, personalized risk was calculated and sequential surgical strategies were monitored using risk-adjusted cumulative sum (RA-CUSUM) analysis. RESULTS: Among the 736 patients, clinical AL occurred in 65 patients (8.8%). Sex, an American Society of Anesthesiologists score, operation time, blood transfusion, and tumor location were identified as significant predictive factors for AL. Based on these factors, a nomogram was created to predict AL, with a concordance index (C-index) of 0.753 (95% confidence interval, 0.690-0.816). A calibration plot showed good statistical performance on internal validation (bias-corrected C-index of 0.742). The RA-CUSUM curve showed that extended splenic flexure mobilization (SFM) could be the most influential strategy to reduce AL. CONCLUSIONS: Our nomogram for predicting AL after laparoscopic rectal cancer surgery might be helpful to identify the individual risk of AL. Furthermore, extended SFM might be the most appropriate strategy for reducing AL.