Background and study aims: Anal fissure is a prevalent condition characterized by severe pain resulting from a tear in the epithelial layer surrounding the anus. This systematic review aims to assess the effectiveness of both surgical and conservative approaches in the management of anal fissures. Methods: A systematic review was conducted, encompassing randomized controlled trials (RCTs), quasi-experimental, and clinical studies published between 2019 and 2024. A comprehensive literature search was performed in Medline, PubMed, and other databases using keywords such as 'anal fissure,' 'sphincterotomy,' and 'topical treatment.' The study adhered to the PICOS framework and followed the PRISMA guidelines. Quality assessment was conducted using the Joanna Briggs Institute (JBI) criteria, and a total of 38 studies were included in the analysis. Results: Of 38 included studies, 27 investigated conservative treatments and 11 evaluated surgical approaches. Conservative methods - particularly topical diltiazem and nifedipine, botulinum toxin injections, and pelvic floor therapy - were effective in pain reduction and healing for many patients and had mostly mild adverse effects. Surgical LIS demonstrated superior long-term healing in refractory cases. Conclusions: Both surgical and conservative approaches serve as complementary strategies in the management of anal fissures. Surgical methods, particularly LIS, provide an effective treatment option with high success rates, while conservative approaches are beneficial in the early stages and for specific patient populations. (Acta gastroenterol belg., 2025, 88, 333-350).