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Tijuana's Robot Surgeons

— To many, Tijuana's medical reputation is associated with alternative medicine. Cancer patients and others who are seriously ill, disillusioned by mainstream medicine's offers of little hope and harsh treatments, flock to the border city for experimental therapies, legal and illegal. Now the city is acquiring a reputation as a hotspot for the relatively new science of robotic surgery, thanks to one physician.

Dr. Harry Miller, 42, grew up in Mexico City, the son of New Yorkers who had relocated there before he was born. He studied medicine at the Universidad Anahuac in the capital city, graduating in 1985. In Veracruz, he did his surgical residency at the National Medical Center of the Mexican Institute of Social Security, better known by the Spanish acronym IMSS (pronounced eems), a semi government-socialized health-care system serving over 50 million people in Mexico and border regions of the United States. Upon completion of his residency in 1991, Miller opened a practice in Tijuana to be closer to his parents, who had moved from Mexico City to Chula Vista. A dual citizen, he resides in San Diego, yet he keeps his practice in Tijuana. "I'm only licensed to practice in Mexico," he says.

As a general surgeon, Miller became expert in laproscopic surgery, or "minimally invasive surgery." Instead of making incisions and operating directly on a patient's organs, in laproscopic surgery, a micro camera on the end of a fiber-optic cable is passed though a centimeter-wide incision. The image from the micro camera is displayed on a monitor, amplified up to 20 times. Then, through other tiny incisions, instruments are passed into the abdominal cavity. While an assistant works the camera, the surgeon uses these instruments to perform the surgery. "Nowadays, we can do with minimally invasive surgery spleen surgery, gall bladder, colonic surgery, pancreatic surgery, a whole bunch of things," Miller says.

Though it's a relatively new art, laproscopic surgery is undergoing a revolution due to robotics developed in the last decade. A soft-spoken, medium-sized man with a pleasant smile and thinning blond hair, Dr. Miller was quick to see the revolution coming. And now, nine years later, he has trained almost all of the doctors competent in robotic surgery in Latin America. Miller starts his story in 1993. "There was a big meeting in San Diego that year," he recalls, "called Medicine Meets Virtual Reality. An expert in robotics named Dr. Yulun Wang -- he had done projects for NASA making arms used in space -- came to that convention with an idea; in laproscopic surgery, one problem is the person holding the camera can get lost. They put the camera in there and sometimes they don't know where to go and they get lost. Or maybe they had a couple of tequilas the night before, or a big fight with their spouse that morning, and their hands are a little shaky. It's very frustrating for the person who's doing the surgery. So they sent Dr. Wang to Dr. Jonathan Sackiert at UCSD, who was very surprised and very pleased with the idea. They both got together and formed a company called Computer Motions, and they developed the first robotic scope holder. It was called Aesop 1000. Aesop stands for automated endoscopic system for optimal positioning. So, in 1993, they did the first laproscopic gall-bladder case at UCSD. They used this robotic system. The way it worked was, the surgeon was using both arms for the surgery, but with his foot he had a pedal control with which he could move the scope around. And it had memory positions; it could go back to previously set positions."

When Miller heard about the robot-aided surgery he grew excited about the concept, and he wanted to learn more. "I called Jonathan Sackiert," he recalls with a laugh, "and I told him, 'I'm Harry Miller. I'm a surgeon in Tijuana. I want to train in robotic surgery.' Maybe it was my English name, but he thought it was a joke."

Once Miller made it clear that he wasn't joking, Sackiert agreed to train him in the field. In 1996, Miller and a friend, Dr. Adrian Carbajal of Mexico City, performed the first robotic surgery in Mexico. "In 1996," Miller says, "we spoke to Yulun Wang from Computer Motions, and we borrowed an Aesop 1000 model, and we brought it down to Tijuana, and we did the first two gall bladders at Regional General Hospital Number 20 of the IMSS." In 1999, Miller started holding "competency courses" in robotic surgery. "I'm the only guy in Mexico teaching it," he says. "I've taught four two-week courses since then. The last one was just finished in February. We had four students. We can't have too many students -- four to six, maximum. I say students, but they're surgeons. They're skilled surgeons who already do minimally invasive surgery, and they want to know what's cooking with robotic surgery. One of the students came from Spain. Another one came from Mexico City, a very renowned surgeon who has written books; and two local students that were here in Tijuana. It's a two-week educational program. This year, what we did is, we took the students and they did 20 cases in our hospital. We did hernia repairs endoscopically, we did gall- bladder surgeries, and reflux surgery."

The students in Miller's course learn on the latest version of the Aesop scope holder, the 3000, which is equipped with a voice-activated system instead of the foot pedal or remote hand control of earlier models. The new model features a greater range of motion than the two previous. "Aesop 1000 and 2000 have 6 degrees of freedom," Miller explains. "Movement along one line in space is 1 degree of freedom. For laproscopic surgery, we need robotics with at least 5 degrees of freedom. Aesop 3000 has 7 degrees of freedom, plus voice activation. For comparison, a human hand and wrist has over 23 degrees of freedom."

Miller's students also become competent on another surgical robot manufactured by Computer Motions, which is headquartered near Santa Barbara, called Zeus. "It's used for microendoscopic abdominal or chest surgery. Zeus has three robotic arms. One of the robotic arms is Aesop -- the model 3000. The other two arms are controlled remotely by the surgeon, who sits at a console away from the operating table. He controls one of Zeus's arms with his right hand and another with his left hand, and the scope with voice commands."

The latest version of the Zeus machine features micro wrists at the end of the instruments that give surgeons nine degrees of freedom, allowing them to perform complicated suturing knots on internal organs from across the room -- or across an ocean, as happened recently. "It was called Lindbergh Project," Miller explains. "What they did is they had a patient in Strasbourg, France, and a French surgeon named Jacques Marescaux was in New York, and they did a gall-bladder surgery. The patient was a 68-year-old woman. Telecom France has six lines of very wide fiber-optic communication lines, very high speed, laid across the Atlantic. And, using those, they did the surgery with a delay time of 150 milliseconds. Between moving your instruments in New York, the signal going all the way to France, and coming back to New York, it took 150 milliseconds, a sixth or seventh of a second. That permitted the surgeon to do the surgery. They removed her gall bladder and they released her 48 hours later. That proved, for the first time on a human patient, that you can do surgery at a very long distance."

Currently, the costs of the surgical robots -- $100,000 for Aesop, a million dollars for Zeus -- are too high for most Mexican health-care systems, especially considering that the surgeries they facilitate can be performed without them. But Miller believes that robotics are the future and points out that they already save money by lowering the number of operating-room personnel and shortening expensive operating room and recovery times. He says the IMSS has expressed interest in acquiring the robots, though to date, they haven't done so.

In all, Miller has trained around 30 surgeons in robotic surgery. Half of them are in Tijuana, making the border city the leader in Mexico -- and among the leaders of the world -- in the field of robotic surgery. Asked how much he charges for the course, Miller answers, "I don't ask them for a nickel. They don't pay for it."

Though not a boastful type, when pressed, Miller admits that he's proud to be boosting the standing of medicine in Tijuana and Mexico. "I'm trying to make something happen faster than it should happen naturally in Mexico," he says. "We usually lag behind the States in technology. But if we can get help from American companies, and they bring down all the technology, we're making the future come faster to Latin America. And we want the world to see that if you give Mexican surgeons these instruments, they're as skilled as anybody in any part of the world."

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— To many, Tijuana's medical reputation is associated with alternative medicine. Cancer patients and others who are seriously ill, disillusioned by mainstream medicine's offers of little hope and harsh treatments, flock to the border city for experimental therapies, legal and illegal. Now the city is acquiring a reputation as a hotspot for the relatively new science of robotic surgery, thanks to one physician.

Dr. Harry Miller, 42, grew up in Mexico City, the son of New Yorkers who had relocated there before he was born. He studied medicine at the Universidad Anahuac in the capital city, graduating in 1985. In Veracruz, he did his surgical residency at the National Medical Center of the Mexican Institute of Social Security, better known by the Spanish acronym IMSS (pronounced eems), a semi government-socialized health-care system serving over 50 million people in Mexico and border regions of the United States. Upon completion of his residency in 1991, Miller opened a practice in Tijuana to be closer to his parents, who had moved from Mexico City to Chula Vista. A dual citizen, he resides in San Diego, yet he keeps his practice in Tijuana. "I'm only licensed to practice in Mexico," he says.

As a general surgeon, Miller became expert in laproscopic surgery, or "minimally invasive surgery." Instead of making incisions and operating directly on a patient's organs, in laproscopic surgery, a micro camera on the end of a fiber-optic cable is passed though a centimeter-wide incision. The image from the micro camera is displayed on a monitor, amplified up to 20 times. Then, through other tiny incisions, instruments are passed into the abdominal cavity. While an assistant works the camera, the surgeon uses these instruments to perform the surgery. "Nowadays, we can do with minimally invasive surgery spleen surgery, gall bladder, colonic surgery, pancreatic surgery, a whole bunch of things," Miller says.

Though it's a relatively new art, laproscopic surgery is undergoing a revolution due to robotics developed in the last decade. A soft-spoken, medium-sized man with a pleasant smile and thinning blond hair, Dr. Miller was quick to see the revolution coming. And now, nine years later, he has trained almost all of the doctors competent in robotic surgery in Latin America. Miller starts his story in 1993. "There was a big meeting in San Diego that year," he recalls, "called Medicine Meets Virtual Reality. An expert in robotics named Dr. Yulun Wang -- he had done projects for NASA making arms used in space -- came to that convention with an idea; in laproscopic surgery, one problem is the person holding the camera can get lost. They put the camera in there and sometimes they don't know where to go and they get lost. Or maybe they had a couple of tequilas the night before, or a big fight with their spouse that morning, and their hands are a little shaky. It's very frustrating for the person who's doing the surgery. So they sent Dr. Wang to Dr. Jonathan Sackiert at UCSD, who was very surprised and very pleased with the idea. They both got together and formed a company called Computer Motions, and they developed the first robotic scope holder. It was called Aesop 1000. Aesop stands for automated endoscopic system for optimal positioning. So, in 1993, they did the first laproscopic gall-bladder case at UCSD. They used this robotic system. The way it worked was, the surgeon was using both arms for the surgery, but with his foot he had a pedal control with which he could move the scope around. And it had memory positions; it could go back to previously set positions."

When Miller heard about the robot-aided surgery he grew excited about the concept, and he wanted to learn more. "I called Jonathan Sackiert," he recalls with a laugh, "and I told him, 'I'm Harry Miller. I'm a surgeon in Tijuana. I want to train in robotic surgery.' Maybe it was my English name, but he thought it was a joke."

Once Miller made it clear that he wasn't joking, Sackiert agreed to train him in the field. In 1996, Miller and a friend, Dr. Adrian Carbajal of Mexico City, performed the first robotic surgery in Mexico. "In 1996," Miller says, "we spoke to Yulun Wang from Computer Motions, and we borrowed an Aesop 1000 model, and we brought it down to Tijuana, and we did the first two gall bladders at Regional General Hospital Number 20 of the IMSS." In 1999, Miller started holding "competency courses" in robotic surgery. "I'm the only guy in Mexico teaching it," he says. "I've taught four two-week courses since then. The last one was just finished in February. We had four students. We can't have too many students -- four to six, maximum. I say students, but they're surgeons. They're skilled surgeons who already do minimally invasive surgery, and they want to know what's cooking with robotic surgery. One of the students came from Spain. Another one came from Mexico City, a very renowned surgeon who has written books; and two local students that were here in Tijuana. It's a two-week educational program. This year, what we did is, we took the students and they did 20 cases in our hospital. We did hernia repairs endoscopically, we did gall- bladder surgeries, and reflux surgery."

The students in Miller's course learn on the latest version of the Aesop scope holder, the 3000, which is equipped with a voice-activated system instead of the foot pedal or remote hand control of earlier models. The new model features a greater range of motion than the two previous. "Aesop 1000 and 2000 have 6 degrees of freedom," Miller explains. "Movement along one line in space is 1 degree of freedom. For laproscopic surgery, we need robotics with at least 5 degrees of freedom. Aesop 3000 has 7 degrees of freedom, plus voice activation. For comparison, a human hand and wrist has over 23 degrees of freedom."

Miller's students also become competent on another surgical robot manufactured by Computer Motions, which is headquartered near Santa Barbara, called Zeus. "It's used for microendoscopic abdominal or chest surgery. Zeus has three robotic arms. One of the robotic arms is Aesop -- the model 3000. The other two arms are controlled remotely by the surgeon, who sits at a console away from the operating table. He controls one of Zeus's arms with his right hand and another with his left hand, and the scope with voice commands."

The latest version of the Zeus machine features micro wrists at the end of the instruments that give surgeons nine degrees of freedom, allowing them to perform complicated suturing knots on internal organs from across the room -- or across an ocean, as happened recently. "It was called Lindbergh Project," Miller explains. "What they did is they had a patient in Strasbourg, France, and a French surgeon named Jacques Marescaux was in New York, and they did a gall-bladder surgery. The patient was a 68-year-old woman. Telecom France has six lines of very wide fiber-optic communication lines, very high speed, laid across the Atlantic. And, using those, they did the surgery with a delay time of 150 milliseconds. Between moving your instruments in New York, the signal going all the way to France, and coming back to New York, it took 150 milliseconds, a sixth or seventh of a second. That permitted the surgeon to do the surgery. They removed her gall bladder and they released her 48 hours later. That proved, for the first time on a human patient, that you can do surgery at a very long distance."

Currently, the costs of the surgical robots -- $100,000 for Aesop, a million dollars for Zeus -- are too high for most Mexican health-care systems, especially considering that the surgeries they facilitate can be performed without them. But Miller believes that robotics are the future and points out that they already save money by lowering the number of operating-room personnel and shortening expensive operating room and recovery times. He says the IMSS has expressed interest in acquiring the robots, though to date, they haven't done so.

In all, Miller has trained around 30 surgeons in robotic surgery. Half of them are in Tijuana, making the border city the leader in Mexico -- and among the leaders of the world -- in the field of robotic surgery. Asked how much he charges for the course, Miller answers, "I don't ask them for a nickel. They don't pay for it."

Though not a boastful type, when pressed, Miller admits that he's proud to be boosting the standing of medicine in Tijuana and Mexico. "I'm trying to make something happen faster than it should happen naturally in Mexico," he says. "We usually lag behind the States in technology. But if we can get help from American companies, and they bring down all the technology, we're making the future come faster to Latin America. And we want the world to see that if you give Mexican surgeons these instruments, they're as skilled as anybody in any part of the world."

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