The Ross operation is a technically demanding procedure. The pressure on the surgeon to produce consistently good results from the very first operation is great, since he is not afforded the luxury of a very soft "learning curve", as is the case with many technically difficult operations, due to the availability of acceptable and safe alternatives for most Ross candidates. We have felt this pressure from the outset and this has motivated a commitment to the development of a systematic surgical technique in an attempt to achieve consistently excellent results. Maintenance of normal autograft spatial geometry after translocation to the aortic position is necessary to ensure proper leaflet coaptation and to avoid autograft insufficiency, and this is the underlying principle upon which this technique is based. Most Ross operations are now performed as total aortic root replacements with a free-standing autograft, However, the autograft is soft and compliant, and will adapt to the dimensions of the more solid tissue into which it is inserted, the aortic annulus proximally and ascending aorta distally, and root replacement will not guarantee that normal autograft geometry will be maintained unless there is a correct size match between the autograft and the aortic annulus and sino-tubular junction, and the autograft is not distorted in other ways. A systematic technical approach to the Ross operation so that size mismatch is avoided and autograft geometry is maintained has been developed and is described in step-by-step detail. In the first third of this series of 85 patients, two patients had moderate (2+) and three patients had mild (1+) immediate postoperative autograft insufficiency. As our understanding of the important sizing and orientation issues has increased and the systematic technique has evolved, the incidence of early autograft insufficiency has essentially been eliminated. In the latter 2/3 of the series, all patients had less than mild autograft insufficiency, except one patient who had mild (1+) insufficiency. We believe that these results validate the principles on which this systematic technical approach is based and that the methods described will help both current and future Ross surgeons perform consistently successful operations.