we developed a basic modular training program ( mtp ) , specially designed for pediatric surgeons . the aim of this study was to investigate whether our current mtp is effective for pediatric surgeons and whether their previous laparoscopic experience affects the training results . nine surgeons who participated in mtp ( 7 males , 2 females , mean age 36.85.8 years , range 30 to 45 years ) were assigned to this study . they were qualified by the japanese surgical society after 4 years of residency in general surgery , and they had been in pediatric surgery practice for 1 to 15 years ( mean 7.3 years ) . they were divided into 2 groups according to their clinical experience in laparoscopic surgery prior to mtp : group a ( n=4 ) , surgeons who had experienced more than 10 cases of laparoscopic surgery ; group b ( n=5 ) , those who had experienced fewer than 10 cases . because surgeons in group b had completed their surgical residency before the  laparoscopic era ,  their age and postgraduate years were significantly higher than those of surgeons in group a ( table 1 ) . profile of modular training program participants each surgeon participated in the standardized 3-hour - mtp workshop , which consisted of an introductory video , a didactic session about instrumentation , and 2  see - through  and 3  laparoscopic  tasks . see - through tasks were done as follows in an original training box made of acrylic acid resin , which mimicked the small abdomen of pediatric patients : with the use of 2 pegboards and 10 pegs , each examinee was required to lift each peg from 1 pegboard with the left hand , transfer it to the right hand , and place it on the other pegboard ( figure 1a ) . modular training units : a. peg transferring task in  see - through  module ; b. pattern cutting task in  see - through  module ; c. laparoscopic training box , laparotrainer , with built - in light source , trocars , scope , and videomonitor in place . this task involved cutting a 6-cm diameter circular pattern out of a 10 x 10-cm piece of white paper placed in the box ( figure 1b ) . the aim was to use the grasper in 1 hand , placing the material under tension while cutting with the endoscopic scissors in the other hand . after completing the see - through tasks , the participants then proceeded to the laparoscopic session . the tasks were done in a laparoscopic training box ( laparo trainer , nippon stryker , japan ) covered by an opaque membrane ( figure 1c ) . two 12-mm trocars were placed through the membrane at convenient working angles on either side of a 10-mm zero - degree rigid scope , which was mounted on a stand at a fixed focal length . the following 3 tasks were done laparoscopically by displaying the modules on a high - resolution video monitor ( vt-21g1 , sharp , japan ) placed in line with the operator . the examinee was required to perform the peg transferring in the same way as in the see - through session . the aim was to get eye - hand coordination and ambidexterity under laparoscopic visual control . this task involved placing 3 hemostatic clips on a tubular foam structure with appropriate margins and then cutting halfway between the clips . each operator was required to twist the metal wire placed through a sucking disc with 2 hands . this task was designed to develop the right and left hand coordination that is necessary for manual knot tying . each participant 's performance was objectively evaluated before and after mtp with the computer - generated virtual simulator ( mist vr , virtual presence inc . , uk ) , which has recently been reported as a confidential tool for objective assessment of psychomotor skills in laparoscopic surgery ( figure 2a ) . participants were required to perform a simple virtual task that involved picking up a virtual ball , placing it in a virtual box , and then releasing it ( figures 2b , 2c , 2d ) . path lengths , path velocities and distances to target profiles were recorded , and the following 3 scores were obtained : ( 1 ) a number of mispointing target balls ( as an indicator of movement precision ) ; ( 2 ) an actual / ideal path length ratio of the movements ( as movement efficiency ) ; ( 3 ) a time taken to complete the virtual task ( as speed ) . computer - generated virtual simulator , mist vr : a. whole view of system with interface ; b. starting task by picking up a virtual ball on pc screen ; c. transferring the ball into a box ; d. terminating task by releasing the target . the data were analyzed with the student paired t test to test differences in performance between before and after mtp and the unpaired t test between groups a and b. a value of p<0.05 was considered statistically significant . nine surgeons who participated in mtp ( 7 males , 2 females , mean age 36.85.8 years , range 30 to 45 years ) were assigned to this study . they were qualified by the japanese surgical society after 4 years of residency in general surgery , and they had been in pediatric surgery practice for 1 to 15 years ( mean 7.3 years ) . they were divided into 2 groups according to their clinical experience in laparoscopic surgery prior to mtp : group a ( n=4 ) , surgeons who had experienced more than 10 cases of laparoscopic surgery ; group b ( n=5 ) , those who had experienced fewer than 10 cases . because surgeons in group b had completed their surgical residency before the  laparoscopic era ,  their age and postgraduate years were significantly higher than those of surgeons in group a ( table 1 ) . profile of modular training program participants each surgeon participated in the standardized 3-hour - mtp workshop , which consisted of an introductory video , a didactic session about instrumentation , and 2  see - through  and 3  laparoscopic  tasks . see - through tasks were done as follows in an original training box made of acrylic acid resin , which mimicked the small abdomen of pediatric patients : with the use of 2 pegboards and 10 pegs , each examinee was required to lift each peg from 1 pegboard with the left hand , transfer it to the right hand , and place it on the other pegboard ( figure 1a ) . modular training units : a. peg transferring task in  see - through  module ; b. pattern cutting task in  see - through  module ; c. laparoscopic training box , laparotrainer , with built - in light source , trocars , scope , and videomonitor in place . this task involved cutting a 6-cm diameter circular pattern out of a 10 x 10-cm piece of white paper placed in the box ( figure 1b ) . the aim was to use the grasper in 1 hand , placing the material under tension while cutting with the endoscopic scissors in the other hand . after completing the see - through tasks , the participants then proceeded to the laparoscopic session . the tasks were done in a laparoscopic training box ( laparo trainer , nippon stryker , japan ) covered by an opaque membrane ( figure 1c ) . two 12-mm trocars were placed through the membrane at convenient working angles on either side of a 10-mm zero - degree rigid scope , which was mounted on a stand at a fixed focal length . the following 3 tasks were done laparoscopically by displaying the modules on a high - resolution video monitor ( vt-21g1 , sharp , japan ) placed in line with the operator . the examinee was required to perform the peg transferring in the same way as in the see - through session . the aim was to get eye - hand coordination and ambidexterity under laparoscopic visual control . this task involved placing 3 hemostatic clips on a tubular foam structure with appropriate margins and then cutting halfway between the clips . each operator was required to twist the metal wire placed through a sucking disc with 2 hands . this task was designed to develop the right and left hand coordination that is necessary for manual knot tying . each participant 's performance was objectively evaluated before and after mtp with the computer - generated virtual simulator ( mist vr , virtual presence inc . , uk ) , which has recently been reported as a confidential tool for objective assessment of psychomotor skills in laparoscopic surgery ( figure 2a ) . participants were required to perform a simple virtual task that involved picking up a virtual ball , placing it in a virtual box , and then releasing it ( figures 2b , 2c , 2d ) . path lengths , path velocities and distances to target profiles were recorded , and the following 3 scores were obtained : ( 1 ) a number of mispointing target balls ( as an indicator of movement precision ) ; ( 2 ) an actual / ideal path length ratio of the movements ( as movement efficiency ) ; ( 3 ) a time taken to complete the virtual task ( as speed ) . computer - generated virtual simulator , mist vr : a. whole view of system with interface ; b. starting task by picking up a virtual ball on pc screen ; c. transferring the ball into a box ; d. terminating task by releasing the target . the data were analyzed with the student paired t test to test differences in performance between before and after mtp and the unpaired t test between groups a and b. a value of p<0.05 was considered statistically significant . table 2 summarizes the training results of overall participants . the time taken to complete tasks was significantly decreased after mtp , indicating the increased speed with which the participants handled the virtual tasks . no significant differences occurred in the number of mispointings and the actual / ideal path ratio of both dominant and nondominant hands before and after mtp . participants ' overall performance table 3 shows the changes of performance before and after mtp in each group and the comparison of performance between 2 groups at each time point . performance of each group p < 0.05 vs before modular training program in group a. p < 0.05 vs before modular training program in group b. in group a , no significant differences occurred in the number of mispointings , the path ratio and the time before and after mtp . in group b , however , the path ratio of dominant hands was significantly decreased after mtp , indicating the significantly higher movement efficiency . the time was also decreased significantly after mtp , indicating the increased speed in this group . before mtp , the path ratio of dominant hands was significantly higher in group b than in group a , indicating the significantly lower movement efficiency in group b. after mtp , a significant difference no longer existed in the path ratio between the 2 groups . table 2 summarizes the training results of overall participants . the time taken to complete tasks was significantly decreased after mtp , indicating the increased speed with which the participants handled the virtual tasks . no significant differences occurred in the number of mispointings and the actual / ideal path ratio of both dominant and nondominant hands before and after mtp . table 3 shows the changes of performance before and after mtp in each group and the comparison of performance between 2 groups at each time point . performance of each group p < 0.05 vs before modular training program in group a. p < 0.05 vs before modular training program in group b. in group a , no significant differences occurred in the number of mispointings , the path ratio and the time before and after mtp . in group b , however , the path ratio of dominant hands was significantly decreased after mtp , indicating the significantly higher movement efficiency . the time was also decreased significantly after mtp , indicating the increased speed in this group . before mtp , the path ratio of dominant hands was significantly higher in group b than in group a , indicating the significantly lower movement efficiency in group b. after mtp , a significant difference no longer existed in the path ratio between the 2 groups . despite the wide acceptance of laparoscopic surgery among general surgeons , most pediatric surgeons remain unconvinced that laparoscopic surgery can be a valuable modality for pediatric surgical disorders . the major reasons are the lack of proven long - term benefits , the question of increased complication rates , the longer operating time and the higher cost of equipment . another reason is that only a few pediatric surgeons have the opportunity to obtain endoscopic skills adequately and appropriately . the most natural place to learn surgical skills is in the operating theater ; however , it is becoming increasingly difficult for present and future surgeons to acquire all surgical skills in the operating room , largely because of concern about safety , time , and cost . it is therefore considered essential to establish a structured endoscopic training program outside the operating rooms , but to our knowledge , no previous study has been conducted regarding the development of such training courses for pediatric surgeons . our current mtp regimen includes 5 standard training tasks , 2 of which were done under 3-dimensional visualization in an original , transparent training box . the box has 15- to 20-cm widths and 10- to 20-cm depths , simulating the insufflated abdomen of infants . two small holes drilled on the surface of the box mimic the surgical ports ; thus , each trainee can realize the actual feeling of the fulcrum effect . through repeated simple tasks , participants can gradually feel familiar with the unique action of delicate and long - handled endoscopic instruments . . the participants could complete these 5 modules step by step at their own pace , being mentored by experienced endoscopic instructors . our mtp did improve the psychomotor skills of pediatric surgeons who had been less exposed to laparoscopic surgery . their movement efficiency and speed were significantly improved after mtp , indicating the validity of our current curriculum . on the contrary , surgeons who had already been exposed to laparoscopic surgery could not gain further development of their skills through mtp . these results suggest that our current basic program is effective for initiating the nonlaparoscopic pediatric surgeons , but is not entirely satisfactory for laparoscopic surgeons . it has been a commonly held assumption that younger surgeons have a natural advantage in the development of laparoscopic skills . our present study showed , however , that age did not appear to play a dominant role in the outcome . senior pediatric surgeons who completed mtp could maintain their initial enthusiasm by being convinced that this is partly because our mtp did not have proper modules to develop precise motion . another explanation is that it may take more time to learn precise motion than effective and speedy motion . further modifications are necessary to make mtp more effective in allowing surgeons to learn delicate , not merely quick motion , which seems more essential in clinical settings of pediatric laparoscopic surgery . our training program was effective for pediatric surgeons who have less experience in clinical laparoscopic surgery . a simple , nontime - consuming , and inexpensive training course is an attractive method for nonlaparoscopic pediatric surgeons to obtain basic endoscopic skills and to overcome their mental reservations .