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Abstract Background Image-guided hepatic interventions are integral to the management of infective and neoplastic liver lesions. Over the past decades, 2D US was used for guidance of hepatic interventions; with the recent advances in US technology, 3D US was used to guide the hepatic interventions. This study aimed to illustrate the added value of 3D image-guided hepatic interventions by X matrix technology. Methods This prospective study was performed on 100 patients that were divided into two groups: group A which included 50 patients who were managed by using 2D US probe guidance, and group B which included 50 patients who were managed by using 3D X matrix US probe guidance. Thermal ablation was done for 70 patients; 40 radiofrequency ablation (RFA) (20 by the 2D probe and 20 by the 3D X matrix probe) and 30 microwave ablation (MWA) (15 by the 2D probe and 15 by the 3D X matrix probe). Chemical ablation (PEI) was done for 20 patients (ten by the 2D probe and ten by the 3D X matrix probe). Drainage of hepatic collections and biopsy from undiagnosed hepatic focal lesions were done for ten patients (five by the 2D probe and five by the 3D X matrix probe). Results The efficacy of US-guided hepatic interventions by 3D X matrix probe was higher than the 2D probe but not significantly higher, with a p value of 0.705, 0.5428 for RFA and MWA, respectively, 0.5312 for PEI, and 0.2918 for drainage of hepatic collections and biopsy. The complications related to the use of the 3D X matrix probe were significantly lower than the 2D probe with a p value of 0.003. The timing of the procedure was shorter by the usage of a 3D X matrix probe in comparison with the 2D probe with a p value of 0.08, 0.34 for RFA and PEI and significantly shorter for MWA and drainage of hepatic collection, biopsy with a p value of 0.02, 0.001, respectively. Conclusions 3D US-guided hepatic interventions by X matrix probe have better efficacy, less complication, and shorter time of procedure than the 2D US-guided hepatic interventions.