Measuring the quality of healthcare has become increasingly important, with surgery not exempt from such evaluation. As technological opportunities and novel developments broaden the range and complexity of treatments that can be offered, the strain on resources is increasing in most healthcare systems worldwide. This is particularly the case for universal healthcare systems, where the budget is based on an allowance and care is given on a needs-based assumption. Thus, the quest of measuring what is done and how well is driven from several stakeholders’ perspectives—including governmental monitoring, hospital administrations, clinical specialty organisations and the care givers. However, exactly how healthcare quality should be assessed remains a difficult task. A particular challenge is the quest for defining surgical quality metrics. Some outcome metrics used in the past, such as in-hospital mortality or length of hospital stay after surgery, may not reflect the quality of care per se, especially when measured as a singular outcome. Over the last decade, an emerging trend to measure combined outcomes has emerged—with one such composite endpoint being dubbed as a ‘textbook outcome’. Surgical quality has shifted to measure the patient journey and designate a ‘textbook outcome’ to a favourable (if not entirely uneventful) journey through the healthcare system. A generic definition of a ‘textbook outcome’ is achieved when a patient—after having had surgery—experiences no major complications, no reoperation, no extended length of hospital stay, no readmission after discharge and no postoperative death. Arguably, such patient journeys may only exist in ‘textbooks’ and may not relate to current healthcare challenges by more patients, higher morbidity, more complex interventions, increasing frailty and an ageing population. Hence, the use of a generic definition may also inherently invalidate comparisons between procedures with different complication profiles or hospitals tasked with different demographics and disease types. Thus, an ‘off-the-shelf’ generic definition …