Most patients with hepatocellular carcinoma (HCC) are diagnosed at an intermediate or advanced stage, losing the opportunity for surgical resection. Conversion therapy, which uses non-surgical approaches to render initially unresectable tumors resectable, has gradually become part of routine clinical practice and a research focus. However, multiple challenges remain, including the lack of clear criteria for identifying "potentially resectable" cases, difficulty in selecting individualized systemic regimens from multiple approved options and determining whether to combine them with locoregional therapy, controversy over the necessity of surgery in patients achieving radiological complete response, the need for optimization of perioperative assessment and management, uncertainty in determining the optimal timing of surgery, and the absence of consensus on postoperative sequential systemic therapy regimens and duration. Addressing these issues requires multidisciplinary collaboration and high-quality evidence from multicenter randomized controlled trials. With the accumulation of clinical experience, growing evidence, and advances in treatment, more patients with initially unresectable HCC are expected to gain surgical opportunities and achieve long-term disease-free survival.