OBJECTIVE: The incidence of persistent tracheocutaneous fistula (TCF) in children has dramatically increased with the increasing number of tracheostomies performed earlier in the paediatric population. Despite the various emerging techniques, two fundamental surgical approaches are primary closure and healing by secondary intention. We aim to compare the surgical outcomes between the two procedures. DATA SOURCE: PubMed, EMBASE and Scopus databases were searched from inception to 31 December 2023 with no restrictions on the setting or design of studies. REVIEW METHODS: Data were pooled using a random effects model to assess the success and complication rates between the two surgical techniques. RESULTS: A total of 26 studies were identified with a total of 1263 children. Persistent TCF was surgically treated with primary closure in 24 studies (n = 898), whereas healing by secondary intention was reported in 12 studies (n = 366). The success rate following primary closure and healing by secondary intention is 97.3% (95% CI: 95.7%-99.0%) and 94.0% (95% CI: 91.2%-96.7%), respectively. The pooled rate of complications following primary closure was 14.1% (95% CI: 8.9%-19.4%) and 8.4% (95% CI: 3.4%-13.3%) following healing by secondary intention. CONCLUSION: Based on the pooled results, healing by secondary intention is a safer surgical option in children with persistent TCF.