The incidence of hepatocellular carcinoma (HCC) is increasing in the United States, primarily due to hepatitis C–related liver disease. Nearly 85%–90% of patients with HCC have underlying chronic liver disease or cirrhosis. Advanced tumor burden or prohibitive hepatic dysfunction precludes operative resection in most patients with HCC. Surgical resection is a treatment option with curative intent in patients with HCC not associated with cirrhosis or in patients with well-compensated liver disease. Tumor extent and hepatic function must be assessed preoperatively to avoid postresection hepatic failure, an often fatal condition that may require urgent liver transplantation. Appropriately selected candidates for liver resection have 5-year postoperative survival rates of 40%–70%, but recurrence rates approach 70%, especially in patients with cirrhosis. For this reason, the best resection for patients with HCC and cirrhosis is orthotopic liver transplantation, which has 5-year posttransplant survival rates of 65%–80% in well-selected candidates.