Hepatocellular carcinoma (HCC) is increasingly being detected at a very early-stage due to the wide implementation of the surveillance of at-risk patient populations combined with improved imaging technologies. Whether patients with HCC at a very early stage can be offered local ablation as a first-line treatment option still remains controversial. We retrospectively compared the effectiveness of surgical resection (SR) and radiofrequency ablation (RFA) for Barcelona Clinic Liver Cancer (BCLC) very early-stage HCC in patients with long-term follow-up. Propensity score analysis using inverse probability weighting (IPW) from a large-volume liver centre. We included adult patients who between 2000 and 2013 received a diagnosis of very early-stage HCC (BCLC stage 0; a single tumour ≤2 cm, Child-Pugh A class, eastern cooperative oncology group [ECOG] 0) and who were treated with SR or RFA as the first-line treatment. We identified 1208 patients, 631 in the SR group and 577 in the RFA group. The median follow-up time was 86.2 months. After propensity score analysis using IPW, the 15-year overall survival rates were 60.4% and 51.6% in the SR and RFA group respectively. RFA group showed poorer overall survival than SR group (adjusted hazard ratio, 1.29; P = .0378). The 15-year recurrence-free survival rates were 37% and 23.6% in the SR and RFA group respectively (P < .001). For patients with very early-stage HCC, the SR group was associated with better overall and recurrence-free patient survival compared to the RFA group. Therefore, SR should be considered as the first-line treatment for these patients. © 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.