OBJECTIVE: Hearing loss disproportionately affects low- and middle-income countries (LMICs). Recent advances in cochlear implant surgery have benefitted patients globally, but the risk of complications in LMICs may be heightened due to social and structural factors. This systematic review characterises the types and rates of complications reported in LMICs, while identifying the key barriers and facilitators to safe surgery. DATA SOURCES: Three databases (Ovid MEDLINE, Ovid Embase, and Global Index Medicus) and grey literature were searched from January 1, 2015 to May 30, 2025. REVIEW METHODS: Studies reporting quantitative data on cochlear implant surgery complications were independently reviewed by 2 authors, with conflicts resolved by a third reviewer. RESULTS: Thirty eligible studies from seventeen countries were identified. No studies were based in low-income countries, with 37% and 63% arising from lower-middle-income and upper-middle-income countries, respectively. Pooled average complication rates were higher in lower-middle-income (8.83%) than upper-middle-income countries (5.08%). Complication profiles also varied by income classification, with facial nerve injuries predominating in lower-middle-income countries compared to vertigo/dizziness and device failure in upper-middle-income countries. Thematic analysis identified systemic, procedural, technological, and capacity issues as barriers to safe surgery, whilst highlighting the importance of specialist expertise, perioperative planning, multidisciplinary teams, and widening access initiatives to mitigate these barriers. CONCLUSION: Overall complication rates of cochlear implant surgery in LMICs are comparable to high-income countries, although data may be underreported due to limited follow-up, and complication profiles differ by income classification. Further work is required to overcome the social and structural barriers to safe surgery.