Background Abdominal wall endometriosis (AWE) is the most common type of extrapelvic endometriosis in women of reproductive age, and several studies have compared high-intensity focused ultrasound (HIFU) ablation with surgical resection in the management of AWE; however, the results are controversial. Objective To compare the efficiency and safety of HIFU ablation with surgery in the treatment of AWE. Search strategy Literature on surgery versus HIFU ablation for treating AWE was identified using the PubMed, Embase, Web of Science, China National Knowledge Infrastructure, WANFANG Database and the Cochrane Library databases. Selection Criteria Full-text manuscripts comparing HIFU ablation and surgery for treating AWE were included. Data collection and analysis Two independent reviewers reviewed and extracted data from the articles, and the risk of bias was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. Data analysis was performed using RevMan 5.4. Main results We included 7 studies involving 405 patients. Compared with the surgery group, the immediate posttreatment visual analogue scale (VAS) score was lower in the HIFU group (mean difference [MD] -1.58, 95% CI -2.56 to -0.59), the length of hospitalization was shorter in the HIFU group (MD -1.95 days, 95% CI −2.43 to −1.48), and the incidence of adverse events was lower in the HIFU group (relative risk 0.32, 95% CI 0.15 to 0.65). There was no significant difference in the symptom recurrence rate, VAS score at the 3-, 6- and 12-month follow-ups, or treatment time between the two groups. Conclusions Compared with surgery, immediate postoperative VAS scores were lower, hospitalization times were shorter, and the risk of adverse events were lower in patients receiving HIFU ablation treatment for AWE.