BACKGROUND: A few studies focus on the long-term outcomes and surveillance strategies for patients with hepatocellular carcinoma (HCC) and microvascular invasion (MVI) who experience postoperative recurrence. The aim of this study was to explore the patterns and prognosis of early and late recurrence (ER and LR) after hepatectomy of such patients. METHODS: Consecutive patients with HCC and MVI after hepatectomy from 26 centers in China from 2009 to 2020 were included. Overall survival (OS) and post-recurrence survival (PRS) were compared using the Kaplan-Meier method and log-rank test. RESULTS: Of 2828 included patients, 1200 patients developed ER and 607 patients developed LR. Among patients with recurrence, 1166 patients had intra-hepatic recurrence as the primary site of first recurrence. The median OS times for the ER, LR, and non-recurrence groups were 20.2, 52.6, and 58.9 months, respectively. Besides, patients with ER had shorter PRS (14.3 vs. 18.9 months, p <
0.001) than LR. Compared to extra-hepatic and both intra- and extra-hepatic recurrence, intra-hepatic recurrence had better OS and PRS (p <
0.001). Recurrence patients who underwent regular postoperative surveillance had longer OS (37.1 vs. 23.4 months, p <
0.001) and PRS (21.2 vs. 11.9 months, p <
0.001) compared to those with irregular surveillance. CONCLUSIONS: Patients with HCC and MVI are more likely to develop ER within 1 year, and ER has a worse prognosis compared to LR. Intra-hepatic is the predominant recurrence site in ER and LR. Postoperative surveillance can improve survival outcomes in patients with recurrence.