In elderly patients with solitary small hepatocellular carcinoma, laparoscopic liver resection leads to significantly better overall and disease-free survival compared to radiofrequency ablation, despite higher complication rates.

• Median overall survival for resection was not reached vs. 67.5 months for ablation (5-year: 65.7% vs. 50.0%; p = 0.005).
• Disease-free survival was also superior at 36.8 months for resection vs. 21.3 months for ablation (5-year: 40.2% vs. 34.3%; p < 0.001).

Consider laparoscopic liver resection as the first-line treatment for surgically fit elderly patients, while reserving ablation for those with higher surgical risks or smaller tumors.