Objective: To assess the clinical efficacy of percutaneous thermal ablation and liver resection for small hepatocellular carcinoma by means of systematic review. Methods: The randomized controlled trials concerning percutaneous thermal ablation and hepatectomy for treatment of small liver cancer were collected through literature retrieval from native and foreign databases. The quality of included studies was assessed according to the Cochrane systematic review method and statistical analysis of data was performed using RevMan 5.1.17 software. Results: Four randomized controlled studies finally met the inclusion criteria, with a total of 683 patients, of whom, 340 cases underwent percutaneous thermal ablation and 343 cases underwent hepatectomy. The results of meta-analysis indicated that the 1- and 3-year overall survival rate, 1-year tumor-free survival rate and 1-year local tumor recurrence rate in the patients undergoing either of the two methods had no statistical difference (all P>0.05). The 3-year disease-free survival rate and 2-year local tumor recurrence rate in patients undergoing liver resection were better than those in patients with percutaneous thermal ablation (both P<0.05). The incidence of major complications in patients receiving percutaneous thermal ablation was significantly lower than that in patients undergoing liver resection (P<0.05), and patients after percutaneous thermal ablation showed shorter hospital stay, lower cost and better systemic conditions. Conclusion: For small liver cancer, percutaneous thermal ablation and liver resection present similar short-term efficacy, but liver resection has better long-term results.