AbstractAimThis prospective study aimed to evaluate the safety and efficacy of video‐assisted anal fistula treatment (VAAFT) in complex fistula‐in‐ano (FIA).MethodConsecutive patients presenting with complex FIA were recruited between November 2012 and November 2018. The primary outcome was healing of the fistula.ResultsSeventy‐two patients were included, 39 (54%) of whom were men, with a mean age of 46 (±11) years. The mean follow‐up was 32 (±18) months. Complete healing was achieved in 64 (89%) patients. When persistent and recurrent cases were considered together, the failure rate was 21% and the success rate 79%. When patients failed, they were offered VAAFT again, after which there was an in increase in the healing rate, which overall (primary and secondary) was 86%. There was no statistically significant deterioration in continence. Eight (11%) patients experienced postoperative complications which required no additional surgical intervention.ConclusionVAAFT represents a promising, sphincter‐saving technique for the treatment of complex FIA. It has proved efficacious, with 79% of patients achieving complete healing after its primary application. After a second use, this reached 86%. The main advantage of VAAFT compared with other sphincter‐saving techniques is working under direct vision. VAAFT has a good safety profile with 11% of patients experiencing minor complications, and there is no effect on continence.