San Diego 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."