Purpose <p>This study aimed to compare perioperative and long-term outcomes between laparoscopic (LLR) and open liver resection (OLR) in elderly patients with solitary hepatocellular carcinoma (HCC).</p> Methods <p>The study consecutively included patients aged ≥ 70&#xa0;years who underwent curative liver resection for single HCC at four tertiary centers between January 2015 and December 2021. Perioperative short-term and long-term survival outcomes were compared between the LLR and OLR groups. Propensity score matching (PSM) was performed in a 1:1 ratio to balance baseline characteristics between the two groups. Univariate and multivariate Cox regression analyses were conducted to identify independent risk factors associated with overall survival (OS) and recurrence-free survival (RFS).</p> Results <p>Of the 180 patients, 94 and 86 were included in the LLR and OLR groups, respectively. After PSM, 65 patients were included in each group. Intraoperative blood loss (<i>p</i> = 0.010), operative time (<i>p</i> = 0.021), length of hospital stay (<i>p</i> = 0.021) and 90-day readmission rate (<i>p</i> = 0.048) were significantly lower in the matched LLR than the matched OLR group. Moreover, postoperative ascites complication was less frequent in the matched LLR group (<i>p</i> = 0.046). Long-term survival outcomes were better in the LLR group compared with the OLR group both before and after PSM (for OS: <i>p</i> = 0.019 and 0.003; for RFS: <i>p</i> = 0.023 and 0.012). Multivariate Cox regression analysis found that open hepatectomy was an independent risk factor of OS and RFS for elderly HCC patients compared to laparoscopic approach.</p> Conclusion <p>For selected elderly patients with solitary HCC, particularly those with tumors in locations amenable to a minimally invasive approach, LLR was associated with superior perioperative and long-term survival outcomes compared to OLR.</p> Clinical Trials Registration <p>Not applicable because this is a retrospective observational study.</p>