The introduction of many new surgical technologies is associated with increased costs and uncertainty regarding risks and benefits. Currently, little is known about how decisions are made regarding the adoption of surgical innovations. To study the decision-making process for adoption of advanced laparoscopic surgical procedures at a community hospital in Toronto, Canada, we used qualitative case study methods. Data were collected using semi-structured interviews with key informants. We performed a modified thematic analysis of the data, using the conceptual framework for priority setting known as accountability for reasonableness, which consists of 4 conditions: relevance, publicity, appeals, and enforcement. Several advanced laparoscopic surgical procedures were introduced at the hospital between 2000 and 2005. During that time, there was no structured, explicit process for making decisions about introducing new surgical technologies. Use of the new surgical technologies was relevant, as measured by the perception of patient benefit and alignment with the hospital's strategic priorities. There was no systematic structure in place to oversee publicity, appeals, or enforcement. The decision to adopt advanced laparoscopic surgery at a community hospital in Toronto, Canada, was made primarily on the basis of its relevance to patient care. The process for making decisions about the adoption of new surgical technologies can be improved.