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Proximie recently sat down with Dr. Martin Karamanliev to discuss a pioneering procedure that connected surgeons across continents, and in real-time, whilst his mentor was on a bus in China.
In September 2025, a patient was due to undergo an ectopic kidney pelvic procedure in Pleven, Bulgaria. Upon admission the day before surgery, the surgical team realised that this was not going to be a straightforward operation; the patient needed an anterior resection, which was going to make the procedure considerably more difficult.
To complicate matters further, a change in plans had meant that lead surgeon Professor Dobromir Dimitrov was 7,200km away on an official work visit in China, and it was going to be impossible for him to be physically present to guide his team through a procedure that had now become unexpectedly complex.
The operating surgeon, Martin Karamanliev, was faced with a decision: postpone the surgery, or to proceed using Proximie’s Surgical Suite to facilitate telementoring over an internet transmission path of approximately 11,000 to 13,000km. They had tested Proximie before - over shorter distances and during less difficult procedures - and decided that now was the time to put the technology through its paces.
Time differences and unavoidable scheduling introduced one final complicating factor: Professor Dimitrov was going to be travelling by bus through Chongqing at the time the procedure was due to take place. So while commuting on public transport, several thousand kilometers away in China, Professor Dimitrov used Proximie to virtually scrub into his team’s OR in Bulgaria, so he could guide them through the anterior resection in real time.
“It’s hard to believe he was on a bus in China and we didn’t feel any latency,” said Martin Karamanliev. “We know there was an observed latency of 0.4 - 0.5 seconds, but we couldn’t feel it. I was at the robotic console with my headset on, I could hear him, and he could hear me. He could see the image from the robotic system on his phone, and for me it felt like my mentor was just behind my shoulder. I heard him say, ‘I can see what you see, and we will make it through this together.’ It was amazing.”
The team had already used Proximie on several occasions, first by testing it out while in the room during surgeries to familiarise themselves with the technology, and then with mentors overseeing straightforward operations remotely from locations such as Greece and Dubai.
“Knowing how to operate Proximie meant everything went very smoothly,” said Martin. “We were able to set up Proximie OR in just 90 seconds, so it was incredibly time efficient. I just had to wait a few moments at the console for Professor Dimitrov to connect, and then he started communicating with me. His experience and advice changed the rhythm of the operation for the better. First of all the procedure was safer, and secondly it was quicker because he was able to guide us to the right decisions at the right time.
“There were at least two specific instances during the operation where he was able to say, ‘Look over here: focus on this other part of the operation for a moment, and then everything after that will be easier and better.’ So just from watching the operation, there were clear moments where he was able to make positive changes in our approach and attitude. Every time he directed us to ‘go here’, ‘go there’, or ‘don’t do that, do this’, we felt no latency in his instructions and were able to act on what he was telling us with perfect timing. The experience has been game changing for us.’
Professor Dimitrov’s team has now been using Proximie for telementoring for more than six months, maximising the reach and availability of expertise by enabling the most experienced surgeons to be in the room for procedures they would otherwise have been unable to attend.
“This is a piece of the puzzle that we’ve been missing for a long time, and Proximie has changed everything,’ said Martin. ‘In the most difficult cases, we simply need the most experienced surgeon in the room, and now this is something we can achieve remotely. We are able to have less experienced surgeons performing the operation, and a mentor giving up an hour or so to provide guidance - sometimes even just 15 minutes during the most critical part of a procedure. It’s a huge advantage both for patients and for us, because we can do a higher number of more difficult cases, and complete them with fewer complications and better outcomes.”
The advantages extend beyond the confines of procedure too, with Proximie making it possible to create reliable and comprehensive video records of cases to be reviewed later, or used for training purposes. “Before Proximie, we were trying to use external video recorders that stored the footage on external drives,” said Martin. “We had a lot of operations where something went wrong with the recording and it was a disaster. So at some point we just stopped using it. With Proximie, it’s really easy; you can view all the operations from your phone, computer or tablet, and easily use the footage for debriefing, mentoring trainees or creating presentations. It is transforming the way we teach medical students.”
As far as Professor Dimitrov and his team are concerned, Proximie is the way forward: a new standard in surgical guidance and training that is fast becoming standard practice. “The impact is positive at every level of the surgical procedure,” says Martin. “For patients - whose needs are always at the centre of our practice - the results are safer and better. For younger surgeons, they gain access to on-demand expertise, meaning they can learn more quickly by doing a higher number of difficult cases. And for telementors, they gain freedom by being able to consult on difficult cases from anywhere in the world.”
