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Background Hepatocellular carcinoma (HCC) is one of the most frequent tumors and it is the predominant primitive liver cancer and in most cases associated with cirrhosis, regardless of the etiology. Aim The purpose of this study was to compare the overall survival after percutaneous ablation and resection in patients with a single HCC lesion measuring less than 3 cm in diameter originating on liver cirrhosis. Patients and methods From January 1999 to December 2008 556 consecutive patients were evaluated in our center for HCC. Only patients with cirrhosis and a single nodule < 3cm were taken into consideration: 48 underwent liver resection and 51 treated with percutaneous procedures. Results The minimum follow up was 20 months. The survival rate of resected patients was significantly higher compared to the ablated patients (p=0.0006). Child A was a protective factor for both groups (p=0.0001) and HCV positive patients had worse outcomes (p=0.005). Moreover, age and survival were significantly associated to resected patients (p=0.0195). Early recurrence occurred in 3 patients after resection and in 7 after ablation. Conclusions This experience confirmed that in case of single nodule <3cm in cirrhosis resection must be considered as the primary choice for all patients with adequate functional reserve. Nevertheless the ablative treatment can be considered a good second line option since it ensure good results in terms of survival.