The Bethune Round Table is an annual conference on international surgery that is unique in North America. Hosted by the Office of International Surgery at the University of Toronto, the conference provides a forum for profiling the global realities of surgical need, particularly as they relate to vulnerable and disadvantaged people of low-income countries. The 2004 Bethune Round Table, drawing on input from 4 continents, highlighted "emerging directions." Presentations and discussions focused on the themes of current surgical realities, the implications for surgical education, the role of specialized surgical services and the function of surgical partnerships.