<h3>Study Objective</h3> To compare the outcomes of percutaneous image-guided cryoablation versus surgery for abdominal wall endometriosis (AWE) <h3>Design</h3> Retrospective cohort study of all patients treated for AWE from 01/2000 to 02/2022. <h3>Setting</h3> Academic tertiary health system. <h3>Patients or Participants</h3> Women who underwent cryoablation (n=25) or surgical excision (n=50) for treatment of AWE. <h3>Interventions</h3> Percutaneous image-guided cryoablation versus surgical excision. <h3>Measurements and Main Results</h3> There was no significant difference between patients undergoing cryoablation versus surgery in terms of age (37±4.6 vs 35.9±6.1, p=0.37), parity (2 [2,3] vs 2 [1,3], p=0.53), presence of pelvic endometriosis (68% vs 68%, p=0.99), number of prior surgeries (2 [2,4] vs 2 [2,3], p=0.79) and cesarean deliveries (2 [1,2] vs 1 [1,2], p=0.73). Mean BMI was significantly higher in the cryoablation group (34.6±8.6 vs 28.7±6.8, p=0.005). Most patients in both cryoablation and surgery groups had no prior intervention for AWE (60% vs 78%), however 36% of cryoablation and 22% of surgical patients underwent prior surgical excision of AWE. The most common location was prior CS scar (cryoablation 80% vs surgery 86%). Lesion number and size (cm) was similar for both cryoablation and surgical groups (1 [1,1] vs 1 [1,1], p=0.059, and 2.7 [1.8,4.0] vs 2.6 [1.7,5.0], p=0.97). Median length of hospital stay was similar between groups (cryoablation 1 [0,1] vs surgery 0 [0,2], p=0.42). Complications included wound infection (cryoablation 4%, surgery 6%), hematoma (cryoablation 8%, surgery 4%), edema (cryoablation 12%, surgery 0%). Recurrence after treatment was similar between cryoablation (24%) and surgery (18%) groups (p=0.76). There was significant decrease of pain in both groups, however this decrease was not significantly different between groups p-value 0.83. <h3>Conclusion</h3> Percutaneous image-guided cryoablation seems equivalent to surgical excision for the treatment of AWE in terms of pain reduction and recurrence risk with low risk of complications. It is a potential option to consider for women wanting to avoid surgery or who are not surgical candidates.