Langenbeck's Archives of Surgery

, Volume 401, Issue 4, pp 495–502 | Cite as

Intraoperative image-guided navigation system: development and applicability in 65 patients undergoing liver surgery

  • Vanessa M. Banz
  • Philip C. Müller
  • Pascale Tinguely
  • Daniel Inderbitzin
  • Delphine Ribes
  • Matthias Peterhans
  • Daniel Candinas
  • Stefan WeberEmail author



Image-guided systems have recently been introduced for their application in liver surgery. We aimed to identify and propose suitable indications for image-guided navigation systems in the domain of open oncologic liver surgery and, more specifically, in the setting of liver resection with and without microwave ablation.


Retrospective analysis was conducted in patients undergoing liver resection with and without microwave ablation using an intraoperative image-guided stereotactic system during three stages of technological development (accuracy: 8.4 ± 4.4 mm in phase I and 8.4 ± 6.5 mm in phase II versus 4.5 ± 3.6 mm in phase III). It was evaluated, in which indications image-guided surgery was used according to the different stages of technical development.


Between 2009 and 2013, 65 patients underwent image-guided surgical treatment, resection alone (n = 38), ablation alone (n = 11), or a combination thereof (n = 16). With increasing accuracy of the system, image guidance was progressively used for atypical resections and combined microwave ablation and resection instead of formal liver resection (p < 0.0001).


Clinical application of image guidance is feasible, while its efficacy is subject to accuracy. The concept of image guidance has been shown to be increasingly efficient for selected indications in liver surgery. While accuracy of available technology is increasing pertaining to technological advancements, more and more previously untreatable scenarios such as multiple small, bilobar lesions and so-called vanishing lesions come within reach.


Intraoperative navigation Liver surgery Image guidance Liver ablation 


Authors’ contributions

VMB, DC, MP and SW were responsible for study conception and design and PCM and PT for acquisition of data; VMB, PCM and SW analysed the data; VMB, PCM and SW drafted the manuscript; and DI, DR, MP and DC performed a critical revision of the manuscript.

Compliance with ethical standards

Source of funding

SNSF NCCR COME, Eurostars E!6201, CTI 12196.

Conflict of interest

Vanessa Banz, Philip Müller, Pasquale Tinguely, Daniel Inderbitzin, Delphine Ribes: None.

Daniel Candinas, Stefan Weber: Co-Founder of CAScination.

Matthias Peterhans: CEO and Co-Founder of CAScination.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (KEK 63/11 and KEK 168/11) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standard. For this type of study, formal consent is not required.


  1. 1.
    Herline AJ, Stefansic JD, Debelak JP, Hartmann SL, Pinson CW, Galloway RL et al (1999) Image-guided surgery: preliminary feasibility studies of frameless stereotactic liver surgery. Arch Surg 134:644–649, discussion 649–650CrossRefPubMedGoogle Scholar
  2. 2.
    Giulianotti PC, Coratti A, Sbrana F, Addeo P, Bianco FM, Buchs NC et al (2011) Robotic liver surgery: results for 70 resections. Surgery 149:29–39CrossRefPubMedGoogle Scholar
  3. 3.
    Selle D, Preim B, Schenk A, Peitgen HO (2002) Analysis of vasculature for liver surgical planning. IEEE Trans Med Imaging 21:1344–1357CrossRefPubMedGoogle Scholar
  4. 4.
    Lang H, Radtke A, Liu C, Sotiropoulos GC, Hindennach M, Schroeder T et al (2005) Improved assessment of functional resectability in repeated hepatectomy by computer-assisted operation planning. Hepatogastroenterology 52:1645–1648PubMedGoogle Scholar
  5. 5.
    Cash DM, Miga MI, Glasgow SC, Dawant BM, Clements LW, Cao Z et al (2007) Concepts and preliminary data toward the realization of image-guided liver surgery. J Gastrointest Surg 11:844–859CrossRefPubMedGoogle Scholar
  6. 6.
    Beller S, Hünerbein M, Eulenstein S, Lange T, Schlag PM (2007) Feasibility of navigated resection of liver tumors using multiplanar visualization of intraoperative 3-dimensional ultrasound data. Ann Surg 246:288–294CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Peterhans M, Oliveira T, Banz V, Weber S (2012) Computer-assisted liver surgery: clinical applications and technological trends. Crit Rev Biomed Eng 40:199–220CrossRefPubMedGoogle Scholar
  8. 8.
    Chopra SS, Hünerbein M, Eulenstein S, Lange T, Schlag PM, Beller S (2008) Development and validation of a three dimensional ultrasound based navigation system for tumor resection. Eur J Surg Oncol 34:456–641CrossRefPubMedGoogle Scholar
  9. 9.
    Clements L, Dumpuri P, Chapman W, Dawant BM, Galloway RL, Miga MI (2011) Organ surface deformation measurement and analysis in open hepatic surgery: method and preliminary results from 12 clinical cases. IEEE Trans Biomed Eng 58:2280–2289CrossRefGoogle Scholar
  10. 10.
    Peterhans M, Anderegg S, Gaillard P, Oliveira-Santos T, Weber S (2010) A fully automatic calibration framework for navigated ultrasound imaging. Conf Proc IEEE Eng Med Biol Soc. 1242–1245Google Scholar
  11. 11.
    Peterhans M, vom Berg A, Dagon B, Inderbitzin D, Baur C, Candinas D et al (2011) A navigation system for open liver surgery: design, workflow and first clinical applications. Intl J Comput Assist Radiol Surg 7:7–16CrossRefGoogle Scholar
  12. 12.
    Ribes D, Peterhans M, Anderegg S, Wallach D, Banz V, Kim-Fuchs C et al (2012) Towards higher precision in instrument guided liver surgery: automatic registration of 3D ultrasound with pre-operative MeVis-CT. Intl J Comput Assist Radiol Surg 7(Suppl 1):141–145Google Scholar
  13. 13.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Kaar M, Figl M, Hoffmann R, Birkfellner W, Hummel J, Stock M et al (2013) Automatic patient alignment system using 3D ultrasound. Med Phys 40:041714CrossRefPubMedGoogle Scholar
  15. 15.
    Karnik V, Fenster A, Bax J, Cool D, Gardi L, Gyacskov et al (2010) Assessment of image registration accuracy in three-dimensional transrectal ultrasound-guided proste biopsy. Med Phys 37:802CrossRefPubMedGoogle Scholar
  16. 16.
    Hammill CW, Clements LW, Stefansic JD, Wolf RF, Hansen PD, Gerber DA (2014) Evaluation of a minimally invasive image-guided surgery system for hepatic ablation procedures. Surg Innov 21:419–426CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Kingham TP, Jayaraman S, Clements LW, Scherer MA, Stefansic JD, Jarnagin WR (2013) Evolution of image-guided liver surgery: transition from open to laparoscopic procedures. J Gastrointest Surg 17:1274–1282CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Buchs NC, Volonte F, Pugin F, Toso C, Fusaglia M, Gavaghan K et al (2013) Augmented environments for the targeting of hepatic lesions during image-guided robotic liver surgery. J Surg Res 184:825–831CrossRefPubMedGoogle Scholar
  19. 19.
    Kenngott HG, Wagner M, Nickel F, Wekerle AL, Preukschas A, Apitz M et al (2015) Computer-assisted abdominal surgery: new technologies. Langenbeck’s Arch Surg 400:273–281CrossRefGoogle Scholar
  20. 20.
    Kenngott HG, Wagner M, Gondan M, Nickel F, Nolden M, Fetzer A et al (2014) Real-time image guidance in laparoscopic liver surgery: first clinical experience with a guidance system based on intraoperative CT imaging. Surg Endosc 28:933–940CrossRefPubMedGoogle Scholar
  21. 21.
    Gillams A, Goldberg N, Ahmed M, Bale R, Breen D, Callstrom M et al (2015) Thermal ablation of colorectal liver metastases: a position paper by an international panel of ablation experts, the interventional oncology sans frontières meeting 2013. Eur Radiol 25:3438–3453CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Vanessa M. Banz
    • 1
  • Philip C. Müller
    • 2
  • Pascale Tinguely
    • 1
  • Daniel Inderbitzin
    • 1
  • Delphine Ribes
    • 2
  • Matthias Peterhans
    • 2
    • 3
  • Daniel Candinas
    • 1
  • Stefan Weber
    • 2
    Email author
  1. 1.Inselspital Berne, Department of Visceral Surgery and MedicineInselspitalBerneSwitzerland
  2. 2.ARTORG Center for Computer-Aided SurgeryUniversity of Berne3010 BerneSwitzerland
  3. 3.CAScination AGBerneSwitzerland

Personalised recommendations