Aims: Accurate localisation of impalpable breast lesions is essential for targeted surgical excision. This study assesses the accuracy and outcomes of surgeon-performed on-table ultrasound guided hookwire (OTHW) localisation of impalpable breast lesions compared with conventional pre-operative radiologist-performed localisation (non-OTHW). Methods: A retrospective review of OTHW cases performed at our centre from 1/1/2024 to 31/12/2025 was conducted and compared with non-OTHW cases over the same period. Patient demographics, surgical waitlist time, operative time, complications, and histology including margin status were analysed. Results: 9 patients underwent surgeon-performed OTHW localisation (7 malignant, 2 benign), compared with 29 non-OTHW patients (22 malignant, 7 benign). Non-OTHW group were localised with Saviscout (n=19), Magseed (n=8) or hookwire (n=2). All lesions were successfully localised and excised. Patients in the OTHW group had a significantly shorter Category 1 surgical waitlist time compared to the non-OTHW group (median 13 days [IQR 10.5-17] vs non-OTHW 19.5 days [IQR 16-26.5], p=0.045). There was no significant difference between groups in median age (OTHW 60 [IQR 48-76] vs non-OTHW 62 [IQR 50-69], p=0.62), median tumour size (OTHW 24mm [IQR 7-27] vs non-OTHW 12mm [IQR 4-24], p=0.10), or median operative time (OTHW 134 minutes [IQR: 120-153] vs non-OTHW 138 minutes [IQR 110-176], p=0.90). One patient in the OTHW group and 2 patients in the non-OTHW group required margin re-excision. No localisation-related or post-operative complications occurred. Conclusions: Surgeon performed on-table hookwire localisation is an accurate, feasible and safe option for selected patients with impalpable breast lesions, associated with a significantly shorter surgical waitlist time and comparable operative and margin outcomes, while avoiding pre-operative awake localisation. Further studies evaluating patient-reported outcomes and cost-effectiveness are warranted.