Surgical Endoscopy

, Volume 31, Issue 10, pp 4315–4324 | Cite as

Laparoscopic image-based navigation for microwave ablation of liver tumors—A multi-center study

  • Pascale TinguelyEmail author
  • Matteo Fusaglia
  • Jacob Freedman
  • Vanessa Banz
  • Stefan Weber
  • Daniel Candinas
  • Henrik Nilsson
New Technology



Stereotactic navigation technology has been proposed to augment accuracy in targeting intrahepatic lesions for local ablation therapy. This retrospective study evaluated accuracy, efficacy, and safety when using laparoscopic image-guided microwave ablation (LIMA) for malignant liver tumors.


All patients treated for malignant liver lesions using LIMA at two European centers between 2013 and 2015 were included for analysis. A landmark-based registration technique was applied for intraoperative tumor localization and positioning of ablation probes. Intraoperative efficiency of the procedure was measured as number of registration attempts and time needed to achieve sufficient registration accuracy. Technical accuracy was assessed as Fiducial Registration Error (FRE). Outcome at 90 days including mortality, postoperative morbidity, rates of incomplete ablations, and early intrahepatic recurrences were reported.


In 34 months, 54 interventions were performed comprising a total of 346 lesions (median lesions per patient 3 (1–25)). Eleven patients had concomitant laparoscopic resections of the liver or the colorectal primary tumor. Median time for registration was 4:38 min (0:26–19:34). Average FRE was 8.1 ± 2.8 mm. Follow-up at 90 days showed one death, 24% grade I/II, and 4% grade IIIa complications. Median length of hospital stay was 2 days (1–11). Early local recurrence was 9% per lesion and 32% per patient. Of these, 63% were successfully re-ablated within 6 months.


LIMA does not interfere with the intraoperative workflow and results in low complication and early local recurrence rates, even when simultaneously targeting multiple lesions. LIMA may represent a valid therapy option for patients with extensive hepatic disease within a multimodal treatment approach.


Liver Ablation Image-guided surgery Surgical navigation Laparoscopy Minimal invasive surgery 



The authors would like to acknowledge Dr. Matthias Peterhans, Delphine Ribes, Denise Baumann and Iwan Paolucci for their contribution to this project. We also thank Prof. Dr. med. Guido Beldi and PD Dr. med. Anja Lachenmayer for their continuous support.

Compliance with ethical standards


Drs. Stefan Weber and Daniel Candinas report grants from CTI and from Eurostars-Eureka during the conduct of the study and are co-founders and shareholders in CAScination AG, manufacturer of the navigation technology under investigation in this study. Drs. Pascale Tinguely, Matteo Fusaglia, Jacob Freedman, Vanessa Banz and Henrik Nilsson have no conflicts of interest or financial ties to disclose.


  1. 1.
    Llovet JM, Schwartz M, Mazzaferro V (2005) Resection and liver transplantation for hepatocellular carcinoma. Semin Liver Dis 25:181–200. doi: 10.1055/s-2005-871198 CrossRefPubMedGoogle Scholar
  2. 2.
    Simmonds PC, Primrose JN, Colquitt JL, Garden OJ, Poston GJ, Rees M (2006) Surgical resection of hepatic metastases from colorectal cancer: a systematic review of published studies. Br J Cancer 94:982–999. doi: 10.1038/sj.bjc.6603033 CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Adam R, Vinet E (2004) Regional treatment of metastasis: surgery of colorectal liver metastases. Ann Oncol Off J Eur Soc Med Oncol 15(Suppl 4):103–106. doi: 10.1093/annonc/mdh912 Google Scholar
  4. 4.
    Lencioni R, de Baere T, Martin RC, Nutting CW, Narayanan G (2015) Image-guided ablation of malignant liver tumors: recommendations for clinical validation of novel thermal and non-thermal technologies- a western perspective. Liver Cancer 4:208–214. doi: 10.1159/000367747 CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    de Jong KP, Wertenbroek MWJLAE (2011) Liver resection combined with local ablation: where are the limits? Dig Surg 28:127–133. doi: 10.1159/000323823 CrossRefPubMedGoogle Scholar
  6. 6.
    Livraghi T, Meloni F, Di Stasi M, Rolle E, Solbiati L, Tinelli C, Rossi S (2008) Sustained complete response and complications rates after radiofrequency ablation of very early hepatocellular carcinoma in cirrhosis: Is resection still the treatment of choice? Hepatology 47:82–89. doi: 10.1002/hep.21933 CrossRefPubMedGoogle Scholar
  7. 7.
    Mahnken AH, Pereira PL, de Baère T (2013) Interventional oncologic approaches to liver metastases. Radiology 266:407–430. doi: 10.1148/radiol.12112544 CrossRefPubMedGoogle Scholar
  8. 8.
    Pathak S, Jones R, Tang JMF, Parmar C, Fenwick S, Malik H, Poston G (2011) Ablative therapies for colorectal liver metastases: a systematic review. Colorectal Dis 13:e252–e265. doi: 10.1111/j.1463-1318.2011.02695.x CrossRefPubMedGoogle Scholar
  9. 9.
    Engstrand J, Nilsson H, Jansson A, Isaksson B, Freedman J, Lundell L, Jonas E (2014) A multiple microwave ablation strategy in patients with initially unresectable colorectal cancer liver metastases- a safety and feasibility study of a new concept. Eur J Surg Oncol 40:1488–1493. doi: 10.1016/j.ejso.2014.05.003 CrossRefPubMedGoogle Scholar
  10. 10.
    Mise Y, Aloia TA, Brudvik KW, Schwarz L, Vauthey J-N, Conrad C (2016) Parenchymal-sparing hepatectomy in colorectal liver metastasis improves salvageability and survival. Ann Surg 263:146–152. doi: 10.1097/SLA.0000000000001194 CrossRefPubMedGoogle Scholar
  11. 11.
    van Vledder MG, Torbenson MS, Pawlik TM, Boctor EM, Hamper UM, Olino K, Choti M a (2010) The effect of steatosis on echogenicity of colorectal liver metastases on intraoperative ultrasonography. Arch Surg 145:661–667. doi: 10.1001/archsurg.2010.124 CrossRefPubMedGoogle Scholar
  12. 12.
    Irshad A, Anis M, Ackerman SJ (2012) Current role of ultrasound in chronic liver disease: surveillance, diagnosis and management of hepatic neoplasms. Curr Probl Diagn Radiol 41:43–51. doi: 10.1067/j.cpradiol.2011.07.003 CrossRefPubMedGoogle Scholar
  13. 13.
    van Duijnhoven FH, Jansen MC, Junggeburt JMC, van Hillegersberg R, Rijken AM, van Coevorden F, van der Sijp JR, van Gulik TM, Slooter GD, Klaase JM, Putter H, Tollenaar RAEM (2006) Factors influencing the local failure rate of radiofrequency ablation of colorectal liver metastases. Ann Surg Oncol 13:651–658. doi: 10.1245/ASO.2006.08.014 CrossRefPubMedGoogle Scholar
  14. 14.
    Sindram D, McKillop IH, Martinie JB, Iannitti DA (2010) Novel 3-D laparoscopic magnetic ultrasound image guidance for lesion targeting. HPB (Oxford) 12:709–716. doi: 10.1111/j.1477-2574.2010.00244.x CrossRefGoogle Scholar
  15. 15.
    Peterhans M, Oliveira T, Banz V, Candinas D, Weber S (2012) Computer-assisted liver surgery: clinical applications and technological trends. Crit Rev Biomed Eng 40:199–220 pii]CrossRefPubMedGoogle Scholar
  16. 16.
    Herline AJ, Stefansic JD, Debelak JP, Hartmann SL, Pinson CW, Galloway RL, Chapman WC (1999) Image-guided surgery: preliminary feasibility studies of frameless stereotactic liver surgery. Arch Surg 134:644-9-50. doi: 10.1001/archsurg.134.6.644 CrossRefGoogle Scholar
  17. 17.
    Peterhans M, vom Berg A, Dagon B, Inderbitzin D, Baur C, Candinas D, Weber S (2011) A navigation system for open liver surgery: design, workflow and first clinical applications. Int J Med Robot 7:7–16. doi: 10.1002/rcs.360 CrossRefPubMedGoogle Scholar
  18. 18.
    Kingham TP, Scherer MA, Neese BW, Clements LW, Stefansic JD, Jarnagin WR (2012) Image-guided liver surgery: intraoperative projection of computed tomography images utilizing tracked ultrasound. HPB (Oxford) 14:594–603. doi: 10.1111/j.1477-2574.2012.00487.x CrossRefGoogle Scholar
  19. 19.
    Banz VM, Müller PC, Tinguely P, Inderbitzin D, Ribes D, Peterhans M, Candinas D, Weber S (2016) Intraoperative image-guided navigation system: development and applicability in 65 patients undergoing liver surgery. Langenbeck’s Arch Surg 401:495–502CrossRefGoogle Scholar
  20. 20.
    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 17:1274–1282. doi: 10.1007/s11605-013-2214-5 CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Langø T, Vijayan S, Rethy A, Våpenstad C, Solberg OV, Mårvik R, Johnsen G, Hernes TN (2012) Navigated laparoscopic ultrasound in abdominal soft tissue surgery: technological overview and perspectives. Int J Comput Assist Radiol Surg 7:585–599. doi: 10.1007/s11548-011-0656-3 CrossRefPubMedGoogle Scholar
  22. 22.
    Fusaglia M, Tinguely P, Banz V, Weber S, Lu H (2016) A novel ultrasound-based registration for image-guided laparoscopic liver ablation. Surg. Innov 23 (4) 397–406CrossRefPubMedGoogle Scholar
  23. 23.
    Harms J, Feussner H, Baumgartner M, Schneider A, Donhauser M, Wessels G (2001) Three-dimensional navigated laparoscopic ultrasonography: first experiences with a new minimally invasive diagnostic device. Surg Endosc 15:1459–1462. doi: 10.1007/s004640090071 CrossRefPubMedGoogle Scholar
  24. 24.
    Hildebrand P, Kleemann M, Schlichting S, Martens V, Besirevic A, Roblick U, Bruch HP, Bürk C (2009) Prototype of an online navigation system for laparoscopic radiofrequency ablation. Hepatogastroenterology 56:1710–1713PubMedGoogle Scholar
  25. 25.
    Rauth TP, Bao PQ, Galloway RL, Bieszczad J, Friets EM, Knaus DA, Kynor DB, Herline AJ (2007) Laparoscopic surface scanning and subsurface targeting: implications for image-guided laparoscopic liver surgery. Surgery 142:207–214. doi: 10.1016/j.surg.2007.04.016 CrossRefPubMedGoogle Scholar
  26. 26.
    Sindram D, Simo KA, Swan RZ, Razzaque S, Niemeyer DJ, Seshadri RM, Hanna E, McKillop IH, Iannitti DA, Martinie JB (2015) Laparoscopic microwave ablation of human liver tumours using a novel three-dimensional magnetic guidance system. HPB (Oxford) 17:87–93. doi: 10.1111/hpb.12315 CrossRefGoogle Scholar
  27. 27.
    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 21:419–426. doi: 10.1177/1553350613508019 CrossRefPubMedGoogle Scholar
  28. 28.
    Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213. doi: 10.1097/ CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Mayo SC, Pawlik TM (2010) Thermal ablative therapies for secondary hepatic malignancies. Cancer J 16:111–117. doi: 10.1097/PPO.0b013e3181d7ea07 CrossRefPubMedGoogle Scholar
  30. 30.
    Hof J, Wertenbroek MWJLAE, Peeters PMJG, Widder J, Sieders E, de Jong KP (2016) Outcomes after resection and/or radiofrequency ablation for recurrence after treatment of colorectal liver metastases. Br J Surg 103:1055–1062. doi: 10.1002/bjs.10162 CrossRefPubMedGoogle Scholar
  31. 31.
    Sindram D, Lau KN, Martinie JB, Iannitti DA (2010) Hepatic tumor ablation. Surg Clin North Am 90:863–876. doi: 10.1016/j.suc.2010.04.014 CrossRefPubMedGoogle Scholar
  32. 32.
    Evrard S, Rivoire M, Arnaud J-P, Lermite E, Bellera C, Fonck M, Becouarn Y, Lalet C, Puildo M, Mathoulin-Pelissier S (2012) Unresectable colorectal cancer liver metastases treated by intraoperative radiofrequency ablation with or without resection. Br J Surg 99:558–565. doi: 10.1002/bjs.8724 CrossRefPubMedGoogle Scholar
  33. 33.
    Philips P, Groeschl RT, Hanna EM, Swan RZ, Turaga KK, Martinie JB, Iannitti DA, Schmidt C, Gamblin TC, Martin RCG (2016) Single-stage resection and microwave ablation for bilobar colorectal liver metastases. Br J Surg 103:1048–1054. doi: 10.1002/bjs.10159 CrossRefPubMedGoogle Scholar
  34. 34.
    Iannitti D a, Martin RCG, Simon CJ, Hope WW, Newcomb WL, McMasters KM, Dupuy D (2007) Hepatic tumor ablation with clustered microwave antennae: the US Phase II trial. HPB (Oxford) 9:120–124. doi: 10.1080/13651820701222677 CrossRefGoogle Scholar
  35. 35.
    Kuang M, Lu MD, Xie XY, Xu HX, Mo LQ, Liu GJ, Xu ZF, Zheng YL, Liang JY (2007) Liver cancer: increased microwave delivery to ablation zone with cooled-shaft antenna–experimental and clinical studies. Radiology 242:914–924. doi: 10.1148/radiol.2423052028 CrossRefPubMedGoogle Scholar
  36. 36.
    Groeschl RT, Pilgrim CHC, Hanna EM, Simo KA, Swan RZ, Sindram D, Martinie JB, Iannitti DA, Bloomston M, Schmidt C, Khabiri H, Shirley LA, Martin RCG, Tsai S, Turaga KK, Christians KK, Rilling WS, Gamblin TC (2014) Microwave ablation for hepatic malignancies: a multiinstitutional analysis. Ann Surg 259:1195–1200. doi: 10.1097/SLA.0000000000000234 CrossRefPubMedGoogle Scholar
  37. 37.
    Leung U, Kuk D, D’Angelica MI, Kingham TP, Allen PJ, DeMatteo RP, Jarnagin WR, Fong Y (2015) Long-term outcomes following microwave ablation for liver malignancies. Br J Surg 102:85–91. doi: 10.1002/bjs.9649 CrossRefPubMedGoogle Scholar
  38. 38.
    Zaidi N, Okoh A, Yigitbas H, Yazici P, Ali N, Berber E (2016) Laparoscopic microwave thermosphere ablation of malignant liver tumors: An analysis of 53 cases. J Surg Oncol 113:130–134. doi: 10.1002/jso.24127 CrossRefPubMedGoogle Scholar
  39. 39.
    Mentha G, Majno PE, Andres A, Rubbia-Brandt L, Morel P, Roth AD (2006) Neoadjuvant chemotherapy and resection of advanced synchronous liver metastases before treatment of the colorectal primary. Br J Surg 93:872–878. doi: 10.1002/bjs.5346 CrossRefPubMedGoogle Scholar
  40. 40.
    Andres A, Toso C, Adam R, Barroso E, Hubert C, Capussotti L, Gerstel E, Roth A, Majno PE, Mentha G (2012) A survival analysis of the liver-first reversed management of advanced simultaneous colorectal liver metastases: a LiverMetSurvey-based study. Ann Surg 256:772-8-9. doi: 10.1097/SLA.0b013e3182734423 CrossRefGoogle Scholar
  41. 41.
    Lam VWT, Laurence JM, Pang T, Johnston E, Hollands MJ, Pleass HCC, Richardson AJ (2014) A systematic review of a liver-first approach in patients with colorectal cancer and synchronous colorectal liver metastases. HPB (Oxford) 16:101–108. doi: 10.1111/hpb.12083 CrossRefGoogle Scholar
  42. 42.
    Feng Q, Wei Y, Zhu D, Ye L, Lin Q, Li W, Qin X, Lyu M, Xu J (2014) Timing of hepatectomy for resectable synchronous colorectal liver metastases: for whom simultaneous resection is more suitable–a meta-analysis. PLoS ONE 9:e104348. doi: 10.1371/journal.pone.0104348 CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Yin Z, Liu C, Chen Y, Bai Y, Shang C, Yin R, Yin D, Wang J (2013) Timing of hepatectomy in resectable synchronous colorectal liver metastases (SCRLM): Simultaneous or delayed? Hepatology 57:2346–2357. doi: 10.1002/hep.26283 CrossRefPubMedGoogle Scholar
  44. 44.
    Kelly ME, Spolverato G, Lê GN, Mavros MN, Doyle F, Pawlik TM, Winter DC (2015) Synchronous colorectal liver metastasis: a network meta-analysis review comparing classical, combined, and liver-first surgical strategies. J Surg Oncol 111:341–351. doi: 10.1002/jso.23819 CrossRefPubMedGoogle Scholar
  45. 45.
    Fitzpatrick JM (2010) The role of registration in accurate surgical guidance. Proc Inst Mech Eng H 224:607–622. doi: 10.1243/09544119JEIM589 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Pascale Tinguely
    • 1
    Email author
  • Matteo Fusaglia
    • 2
  • Jacob Freedman
    • 3
  • Vanessa Banz
    • 1
  • Stefan Weber
    • 2
  • Daniel Candinas
    • 1
  • Henrik Nilsson
    • 3
  1. 1.Department of Visceral Surgery and MedicineInselspital, University Hospital Bern, University of BernBernSwitzerland
  2. 2.ARTORG Center for Biomedical Engineering ResearchUniversity of BernBernSwitzerland
  3. 3.Division of Surgery, Department of Clinical SciencesDanderyd Hospital, Karolinska InstitutetStockholmSweden

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