Impact of surgeon volume on 18-month unclosed ileostomy rate after restorative rectal cancer resection. Tyler et al. For some time, the impact of defunctioning loop ileostomy has been under scrutiny with rates of adverse health outcomes such as acute kidney injury, high output stomata and readmission rates being sobering to say the least. Longer term sequelae of delayed ileostomy closure such as poorer function from low anterior resection syndrome have also come to the fore. Many surgeons are now more questioning of the balance between risk and benefit of creating a loop ileostomy for patients undergoing low anterior resection and several studies have tried to identify risk factors for delayed closure in order to facilitate a more selective approach to loop ileostomy formation. In this month's Editor's Choice paper by Tyler et al the authors have sought to investigate such risk factors further in a UK setting [1]. The novelty of the paper lies in its examination of surgical volume and its relationship to outcomes. In a surprise to almost no one high volume surgeons performed better than low volume ones. But why? The cut off between high and low volumes of five cases per year is low by international standards and even their proposal for 10 cases per year doesn't match the volumes seen in many other countries. Surgical skill alone is unlikely to be sufficient to explain all the outcome differences in this study. What the paper doesn't explore is the improvements in decision making that comes with increased operative volume – both pre and intraoperatively. If in pre-Covid times nearly a third of patients were not having gastrointestinal continuity restored it is time that the processes surrounding the formation and closure of loop ileostomies were more rigorously evaluated as we move forward. Tyler and colleagues are right to highlight that patient selection for low anterior resection versus non-restorative options (TME Hartmann's / abdominoperineal excision) is more challenging and perhaps it is time we as a profession were more introspective and considered failure to close a loop ileostomy as a failure of both patient risk stratification and the shared decision-making process when deciding on the index surgical procedure.