Proximie’s Daring Robot Surgery Saved a Man’s Life
May 18, 2023
Two doctors, separated by thousands of miles, carried out a lifesaving operation using a robot. It’s the start of a major change in how surgery is performed.
IN EARLY APRIL 2020, shortly after the British prime minister Boris Johnson had announced the first pandemic lockdown in the United Kingdom, a urologist named Archie Fernando reached out to one of her colleagues, Nadine Hachach-Haram.
The two doctors worked at Guy’s and St Thomas’ hospital, one of the busiest in the country, at a time when nearly a thousand people were dying of Covid-19 every week. Most surgeries were being deferred, except for life-or-limb cases and urgent cancer surgeries, and Hachach-Haram, who is a reconstructive plastic surgeon, recalls how useless she felt. “I would just walk into the wards and ask the nurses what I could do to help,” she says. “I started doing everything, like portering and proning, turning patients over to make their breathing slightly better.”
Hachach-Haram was also the founding CEO of a small health-tech startup called Proximie. The company had developed an augmented reality platform that allowed surgeons to collaborate remotely. Its web-based software enabled surgeons to talk to each other while sharing a live video stream of an operation—including up to four feeds displaying different camera perspectives and medical scans—and featured a computer-generated overlay which could be used to draw instructions on the shared screen.
Fernando wanted to use Proximie for an urgent and complicated procedure. Her patient was Mo Tajer, a 31-year-old man who had undergone chemotherapy for testicular cancer. The cancer had spread into his abdomen, where a 5-centimeter tumor was attached around the aorta and the inferior vena cava, two of the largest blood vessels in the body, making its surgical excision challenging. In normal circumstances, Fernando would have performed an open surgery, but this would have also required a two-week postoperative recovery period in the intensive care ward during the peak of the pandemic. “That’s not an environment where you want someone who’s immunosuppressed to be sitting around,” Hachach-Haram says. “They needed him in and out of the hospital as fast as possible.”
The safer alternative was a minimally invasive robotic keyhole surgery, but Fernando wasn’t experienced enough in that procedure. With Proximie, however, she would be able to operate with the guidance of a colleague, a US-based surgeon named Jim Porter. Porter, who was the medical director for robotic surgery at the Swedish Medical Center in Seattle, had not only pioneered this type of operation, he was also one of the most experienced laparoscopic surgeons currently working.
The surgery took place on May 21. Fernando, wearing full personal protective equipment, operated the console of the surgical robot, two meters away from the patient. The robot has four articulated arms, three fitted with surgical instruments and a fourth holding a thin tube with a camera at the end, which, upon insertion into Tajer’s abdomen, allowed Fernando to see inside the patient. Porter, wearing his pajama robe and sitting at his home in Seattle, had access to that exact same view on his laptop. For five hours, he guided Fernando through the surgery step by step, talking to her while using an augmented-reality pointer to identify anatomical parts and drawing annotations to pinpoint where specific incisions should be made.
Hachach-Haram, who had logged in to watch the operation, was “speechless.”
LIKE MOST SURGEONS, the education of Nadine Hachach-Haram followed a pedagogy known in medical circles as “see one, do one, teach one.” It’s a tradition that dictates that trainees, once they have observed a particular type of surgery or use of equipment, should then attempt to perform it, the first few times under supervision and subsequently on their own. After enough firsthand experience has been accumulated, surgeons are then expected to teach those skills to the next generation. Hachach-Haram still vividly remembers the first surgery she observed, at the age of 14. She had moved to Beirut from her native San Diego four years before, in 1990, after her parents had decided to return to their country of origin. Lebanon’s civil war had ended by then, but the fight between the Israeli army and the Lebanese paramilitary group Hezbollah continued unabated, bringing injury and death to masses of innocent civilians. “It wasn’t the safest time to be growing up in Lebanon,” Hachach-Haram says. “You would see a lot of people with serious burns, deformities, limbs missing.”
One day, her family received a visit from a friend, a plastic surgeon from New York who regularly traveled to Lebanon to operate on trauma victims. Hachach-Haram was intrigued, and she convinced him to let her accompany him to one of his surgeries. She watched mesmerized as he operated on a young girl who had a foot contracture, a severe tightening of the skin that restricted her movements. “Her foot had burned from a bomb blast,” Hachach-Haram says. “The surgeon had to do what we call a Z-plasty, where you release a contracture by geometric cuts that allow you to move skin and revise scars. It was astonishing to me that he was able to help her walk again just by moving skin from one place to another.” That was the day Hachach-Haram decided what she wanted to do with her life. She wanted to be just like that plastic surgeon from New York, someone who was willing to fly 9,000 kilometers across the world to operate on someone who desperately needed it. “I wanted to help everyone around the world get that same quality of care,” she says. “I wanted to give people a chance.”
Hachach-Haram would perform her first surgery 12 years later, assisting a senior surgeon on the removal of a thyroid gland as a first-year medical student in London. She went on to specialize as a reconstructive plastic surgeon for breast and pelvic cancer, teaching others as she progressed in her own training. In 2006, she started volunteering for global health charities, flying to places like Peru, Vietnam, and Lebanon to train and learn from local doctors. For a while, she could describe herself as fulfilled. But gradually, over the years, a different feeling began taking hold, a feeling that what she was doing just wasn’t enough.
She recalls one day in particular when that sense of frustration took over. It was April 2015, and she was sitting alone in the operating room, pregnant with her third child, having just returned from yet another long trip and due soon to make another. The Lancet medical journal had just published a report which concluded that nine in 10 people in low- and middle-income countries did not have access to basic surgical care. That cold statistic felt, as she puts it, “like a punch in the guts … I’d been working so hard to try to improve access and help and make all this difference, and suddenly it all just felt futile.”
As she reflected on her own teaching experience, it dawned on her that it wasn’t so much the case that she wasn’t doing enough but that she had been doing it wrong. “I would train people, and then I would never see them again,” she says. “I had no idea how they adopted the technique, if they were doing it properly.” And this inefficacy, she realized, was a direct consequence of the pedagogy of “see one, do one, teach one.” “It was antiquated,” she says. “It just doesn’t scale.”
What the operating room needed, she thought, was an operating system. A digital interface that could connect surgeons during live operations, in a way that they could watch, learn, collaborate, and share expertise, unconstrained by geography. She often describes having this vision of a revolving planet dotted with operating rooms all around the world, all connected in a network.
With the help of a software engineer, by the end of 2015 she had developed an app that allowed surgeons to share a view of their surgical fields remotely and overlay simple illustrations and annotations by drawing on the shared screen. To test the idea, she enlisted a surgeon in California who volunteered for the Global Smile Foundation, which provided cleft palate surgery for children. As part of that program, he traveled to Trujillo, Peru, every three months to train a local doctor. That year, instead, he used Hachach-Haram’s prototype to conduct the training remotely every week. “Within that year, he was able to significantly upskill the Peruvian doctor. They measured that not only had she become more efficient, but her decisionmaking was also quicker,” she says.
A few months later, Hachach-Haram received a call from a colleague working in Gaza who needed her help. He told her that an 18-year-old man had injured his left hand while trying to dismantle an unexploded bomb. Now he couldn’t shower or dress himself. He had undergone six unsuccessful operations with local surgeons and, because of the Israeli blockade, couldn’t travel to seek treatment abroad.
Although Proximie had not been used in a live surgery, Hachach-Haram asked a trauma surgeon in Beirut to assist the local surgeon remotely. “I was very nervous,” she says.” The possibility of changing this person’s life was very important to me. It was like the dream I had since I was 14 coming true.”
The success of that surgery emboldened Hachach-Haram to turn her research project into a proper company. She raised money, hired a team to develop the technology, and spent the next couple of years relentlessly proselytizing at conferences about the digital operating room. “I would fly 10 hours just to give a 10-minute talk,” she says. In 2019, Proximie was ready for its commercial launch.
When the Covid-19 pandemic reached the UK a year later, Proximie had already been used in 1,200 surgeries in over 30 countries. “Like every company in the first few weeks of the pandemic, we announced to our shareholders that we were going to prioritize our mental wellness and just try to survive,” Hachach-Haram says. A week later, she changed her mind. “I realized, hold on a minute, this is exactly when people are going to need our technology,” she says. She called another shareholder meeting and announced: “Scrap the previous plan. We’re going to accelerate.” In six months, the number of users grew tenfold, and the number of surgical sessions increased to 5,500. Today more than 20 percent of NHS hospitals have access to the software. “Before, we were just a sci-fi concept with some potential,” she says. “Suddenly, we were the only way of doing things.”
DUE TO THE suspension of routine operations during the pandemic, Hachach-Haram went many months without performing a single operation. “When we came back to operating, our confidence was hit,” says Hachach-Haram. “We needed to get back into it, so we would buddy up and ask a colleague to help us through it, because we needed that support.”
When it wasn’t possible to have another consultant physically present, many used Proximie to receive remote support instead. If loss of skill and confidence during the pandemic was a concern for experienced surgeons, the problem was even more pronounced for their junior colleagues: According to official data, NHS trainees saw a 50 percent reduction in training opportunities to operate. “Many trainees in the prime of their education missed out on 18 months of practice,” she says. “We don’t have the luxury of taking 10 years to train people. We had to think about how Proximie could accelerate that.”
The Society of American Gastrointestinal and Endoscopic Surgeons, for instance, shipped anatomically realistic porcine tissue models to trainees working from home, so they could practice abdominal wall hernia repairs while being assisted by experts remotely. The Hip Preservation Society, on the other hand, set up a regular virtual education program which included live surgery—a labral reconstruction procedure, for instance, was broadcast to over 500 people all over the world. “Historically, only a couple of trainees would be having access to a procedure,” she says. “Now hundreds could have access to the few cases that were happening.”
Currently, more than 95 percent of the surgical sessions using Proximie are also recorded onto its online library, which enables surgeons to edit and tag footage that can be later used for training or debriefing. This library currently stores more than 20,000 videos of surgeries, making it the largest database of this sort. “When we started we only had in mind the live surgery feature,” she says. “But then we thought, what if people want to have feedback after the operation or to review their performance? That’s why we built the library.” When she first watched footage of her own surgeries, Harach-Haram learned, for instance, that her behavior was, as she describes it, “a bit pushy.” “I noticed I liked to do the operations myself, even when there were trainees in the room,” she says. Now, in similar situations, she forces herself to hand over the surgical instruments, purposefully clasps her hands near her chest, and steps away from the operating table. “I learned not to be in their space,” she says. “I just give them the room.”