Objective:To study the optimal surgical strategy for patients with hepatocellular carcinoma (HCC) presenting with spontaneous rupture and hemorrhage.Methods:The electronic databases of PubMed, Web of Science, Embase, and Cochrane Library were searched, and studies reporting on survival outcomes comparing emergency resection (ER) and transarterial embolization followed by hepatectomy (SH) were included by using predetermined inclusion and exclusion criteria. The perioperative and survival data were compared using the Review Manager 5.3 software.Results:Eight retrospective studies were included. The total sample size was 556, with 285 (51.3%) in the ER group and 271 (48.7%) in the SH group. Perioperative blood loss ( WMD=683.61, 95% CI: 283.36-1 083.86, P=0.0 008) and blood transfusion volume ( WMD=453.43, 95% CI: 250.27-656.58, P<0.0 001) in the SH group were significantly less than those in the ER group. There were no significant differences in operative time, incidences of complications, mortality and recurrence rates of tumors between the two groups (all P>0.05). The 1-, 2-, 3-year overall survival and 1-, 2-, 3-, 5-year disease-free survival of the ER group were not significantly different from those of the SH group (all P>0.05). The 5-year overall survival rate of the ER group was significantly lower than that of the SH group ( HR=1.52; 95% CI: 1.14-2.03, P=0.005). Conclusions:There was no significant difference in short-term outcomes in treatment of ruptured HCC, SH was superior to ER in long-term survival outcomes.