Introduction: This study evaluates the role of radiofrequency ablation under imaging guidance for hepatocellular carcinoma in contemporary surgical practice, assessing its impact on clinical outcomes, procedural accuracy, and patient safety in a retrospective comparative analysis. Materials and Methods: A retrospective comparative study was conducted on 350 patients from January 2015 to December 2022 at a tertiary care center. Patients were divided into CT-guided RFA (n=175) and US-guided RFA (n=175) groups. Primary outcomes included procedural success rate, complication rates, and clinical efficacy measures. Results: The CT-guided RFA group demonstrated significantly improved primary outcomes compared to US-guided RFA (p<0.05). Complication rates were lower in the study group, and procedural efficiency was maintained or improved. Multivariate analysis confirmed the imaging modality as an independent predictor of favorable outcomes. Conclusion: The findings support the integration of advanced imaging guidance in surgical practice, demonstrating measurable improvements in accuracy, safety, and clinical outcomes that justify the investment in imaging technology.