BACKGROUND & AIMS Ablation plays an important role in the treatment of hepatocellular carcinoma. Because image-guided navigation technology has recently entered the clinical setting, we aimed to analyze its safety, therapeutic and procedural efficiency. METHODS Retrospective analysis of patients treated with stereotactic image-guided microwave ablation between 01/2015 and 12/2017. Interventions were performed using computertomography-guidance with needle trajectory, ablation planning and automatic single-marker patient registration. Needle placement and ablation coverage was controlled by image fusion under general anesthesia with jet-ventilation. RESULTS In total 174 ablations were performed in 88 patients during 119 interventions. Mean age was 66 (46-84) years, 74 (84.1%) were men and 74% were Child Pugh Class A. Median tumor size was 16 (4-45) mm, 62.2% were BCLC A. Median lateral and longitudinal error of needle placement were 3.2 (0.2-14.1) and 1.6 (0-15.8) mm. Median one tumor (1-4) was ablated per session. One patient developed a Dindo IIIb (0.8%) complication, 6 minor complications. After re-ablation of 12 lesions, an efficacy rate of 96.3% was achieved. Local tumor progression was 6.3% (11/174). Close proximity to major vessels was significantly correlated with local tumor progression (p