Surgical intervention remains a primary curative option for managing hepatocellular carcinoma (HCC) in low-income countries. Liver resection is considered safer in patients without cirrhosis and in those with Child-Pugh A cirrhosis when portal hypertension is absent. However, preoperative evaluation using indocyanine green clearance is often unavailable in these settings. Instead, upper endoscopy and measurement of hepatic venous pressure gradient are commonly employed to assess portal hypertension before surgery. Postoperative recurrence and hepatic decompensation are frequent challenges following resection. In many low- and middle-income countries (LMICs), where cadaveric organ donation programs are scarce, living donor liver transplantation (LDLT) serves as the only curative option for patients with HCC and advanced cirrhosis. Yet, factors such as limited donor availability, cultural barriers, financial constraints, and resource shortages contribute to high dropout rates among patients awaiting transplantation. Ensuring donor safety through comprehensive preoperative evaluation, implementing stringent legal frameworks to prevent organ trafficking and donor coercion, are essential components of a successful LDLT program. In several countries, outreach transplant initiatives have been launched with support from international surgical societies and visiting experts. Despite national support schemes, the high cost of postoperative care, particularly immunosuppressive therapy, can impact recipient adherence to follow-up care. Some transplant centers sustain their activities through a combination of government funding, community initiatives, and charitable contributions. Although new hepatopancreatobiliary surgical units and transplant programs are emerging in various LMICs with international collaboration, the substantial economic burden remains a significant barrier to widespread implementation.