Purpose: To investigate the ability of a “slowly cutting, loose seton ligature and staged fistulotomy” to heal perianal fistulas, the time needed with the seton ligature, recurrence rate, influence on anal continence, health-related quality of life (HRQoL), and patient satisfaction. Methods: Observational single-center study. We reviewed the medical records of all patients with primary surgeries from January 1, 2009, to December 31, 2018. The patients answered a questionnaire pre- and postoperative on anal continence (St. Mark’s incontinence score) and HRQoL (The Short Health Scale). Satisfaction with the operation was answered postoperatively. Results: Forty-three patients (37 men, 6 women) were included. Initially 41 of 43 healed (95%). Three patients (7%) had a recurrence, two healed after retreatment. The median follow-up was 55 months (IQR, 4). Thirty-four patients (79%) responded to the questionnaire. At follow-up, forty (93%) patients were healed. The median time treated with a seton ligature in the healed patients was 13 months (IQR, 14). St. Mark’s incontinence score preoperative was median 2 (IQR, 9) and after the operation median 1 (IQR, 4). The Short Health Scale improved from median 20 (IQR, 5) preoperatively to 5 (IQR, 5) postoperatively, p < 0.001. Patient satisfaction was median 1 (= very satisfied) (IQR, 1). Conclusion: A “slowly cutting, loose seton ligature followed by a staged fistulotomy”, heals the vast majority of perianal fistulas with minor or none influence on continence and few recurrences. Patient-reported HRQoL improves greatly, and patient satisfaction is high.