The tremendous development of laparoscopic hepatectomy helps to relieve the difficulties encountered during open hepatectomy. Therefore, a difficulty scoring system was produced to assess the difficulty grade of laparoscopic hepatectomy. The aim of this study was to explore whether the IWATE-DSS is comparable to the long-term outcomes of LH for hepatocellular carcinoma. Clinical data from all consecutive patients who underwent laparoscopic hepatectomy for hepatocellular carcinoma at the Sir Run Run Shaw Hospital, Hangzhou, were prospectively collected and reviewed. The difficulty level of the operations was graded using the IWATE-DSS. The perioperative and postoperative outcomes of laparoscopic hepatectomy were compared at each difficulty level. A total of 300 patients underwent laparoscopic hepatectomy for HCC during the study period. The perioperative and postoperative outcomes were significantly different between the groups according to the IWATE-DSS. There were significant differences in both the intraoperative (bleeding controlp= 0.000; surgical timep= 0.000; estimated blood lossp= 0.033) and postoperative variables (postoperative hospital stayp= 0.005) among these four groups. The 5-year disease-free survival decreased significantly along with the LH difficulty score (p= 0.000). The 5-year overall survival also decreased significantly along with the LH difficulty score (p= 0.000). IWATE-DSS was significantly correlated with short- and long-term outcomes in patients who underwent laparoscopic hepatectomy for HCC.