Perianal Crohn’s Disease (PCD) is a debilitating manifestation of Crohn’s disease, associated with high recurrence rates, impaired wound healing, and significant morbidity. Management is complex and typically requires a multidisciplinary approach combining medical and surgical therapies. Conventional surgical interventions are limited by the risk of sphincter injury and suboptimal healing outcomes. Video-Assisted Anal Fistula Treatment (VAAFT) is a minimally invasive, sphincter-preserving endoscopic technique that has emerged as a potential alternative for the management of complex perianal fistulas; however, evidence supporting its use in PCD remains limited. This systematic review evaluated the safety, efficacy, and feasibility of VAAFT in the treatment of PCD. A comprehensive search of all major databases was conducted for studies published between 2011 and 2025. Studies reporting the use of VAAFT in adult patients with PCD were included. Primary outcomes assessed included feasibility, success, healing rates, symptom resolution, and post-procedural complications. Seven single-centre studies met the inclusion criteria, comprising five prospective and two retrospective studies. Feasibility rates ranged from 84% to 96%. VAAFT demonstrated notable diagnostic utility, identifying previously unrecognized fistula tracts in up to 64% of cases. Reported success rates varied widely (27–82%), largely due to heterogeneity in outcome definitions. Complication rates were low, with minimal morbidity and rare continence disturbance. Improvements in pain and discharge were reported in selected studies, alongside favourable patient satisfaction. Overall, VAAFT appears to be a safe and feasible sphincter-preserving option for the multidisciplinary management of PCD. Further large-scale, multicentre randomized studies are required to standardize outcomes and confirm long-term efficacy.