BACKGROUND AND AIMS: Endoscopic surgery (ES) and small bone window craniotomy (SBWC) are commonly used methods for hematoma removal in cases of intracerebral hemorrhage (ICH). However, their long-term efficacy and safety remain uncertain. METHODS: A systematic search was performed in the PubMed, Embase, and Cochrane Library databases from inception to June 30, 2024. The primary outcomes assessed were the 6-month favorable functional outcome rate and the hematoma evacuation rate. Following the meta-analysis, a trial sequential analysis (TSA) was conducted to validate the findings. RESULTS: Six randomized controlled trials were included in the meta-analysis. ES demonstrated a higher 6-month favorable functional outcome rate compared to SBWC (56.8% vs. 48.0%, relative risk [RR] 1.20, 95% confidence interval [CI] 1.05-1.38, I CONCLUSIONS: The meta-analysis and TSA indicate that ES offers better long-term efficacy, shorter operation times, less blood loss, and a lower rate of pneumonia compared to SBWC. Therefore, prioritizing ES over SBWC for treating ICH appears to be a reasonable approach.