Background: Chronic anal fissures represent a common anorectal condition causing significant discomfort and decreasein quality of life. This study aimed to evaluate and compare patient satisfaction and decision-making factors between pharmacological (2% Diltiazem gel) and surgical (lateral internal anal sphincterotomy - LIAS) approaches in the management of chronic anal fissures. Methods: A prospective randomized comparative study was conducted with 100 patients diagnosed with chronic anal fissures, who were divided equally into two treatment groups: pharmacological therapy with 2% Diltiazem gel (n=50) and surgical management with LIAS (n=50). Patients were followed up for six months, with assessment of symptom relief, healing rates, complications, recurrence, and satisfaction scores. Decision-making factors including pain management, fecal incontinence, and side effects were also analyzed. Results: At six months, complete healing was observed in 52% of patients in the Diltiazem group compared to 88% in the LIAS group (p<0.0001). Symptom relief was achieved in 56% and 84% of patients in the Diltiazem and LIAS groups, respectively (p=0.002). Pain scores were significantly lower in the LIAS group at six months (p=0.0013). Recurrence rates were 22% in the Diltiazem group versus 6% in the LIAS group (p=0.021). Patient satisfaction scores were higher in the LIAS group, with 82% reporting satisfaction scores of 7 or above compared to 30% in the Diltiazem group (p<0.0001). Minor side effects (headache, flushing) occurred in 8% of Diltiazem patients, while temporary fecal incontinence was observed in the LIAS group but improved substantially by six months. Conclusion: While both treatments demonstrated efficacy in managing chronic anal fissures, LIAS showed superior results in terms of fissure healing, symptom relief, prevention of recurrence, and overall patient satisfaction. However, the decision-making process should consider individual patient factors including risk tolerance for temporary incontinence versus preference for non-invasive management despite lower efficacy rates.