SUPPLEMENT NO. 1 TO PLEDGE AND SECURITY AGREEMENT

Exhibit 10.4

SUPPLEMENT NO. 1 TO PLEDGE AND SECURITY AGREEMENT

SUPPLEMENT NO. 1 dated as of December 16, 2010, to the Pledge and Security Agreement dated as of June 29, 2007 (as amended, supplemented or otherwise modified from time to time, the “Security Agreement”), among ASC ACQUISITION LLC (“Holdings”), SURGICAL CARE AFFILIATES, LLC (the “Borrower”), certain Subsidiaries of the Borrower from time to time party thereto and JPMORGAN CHASE BANK, N.A., as Administrative Agent for the Secured Parties (as defined below).

A. Reference is made to the Credit Agreement dated as of June 29, 2007 (as amended, supplemented or otherwise modified from time to time, the “Credit Agreement”), among the Borrower, Holdings, JPMorgan Chase Bank, N.A., as Administrative Agent, Swing Line Lender, and L/C Issuer, each lender from time to time party thereto (collectively, the “Lenders” and individually, a “Lender”), X.X. Xxxxxx Securities Inc. and Xxxxxxx Sachs Credit Partners L.P., as joint lead arrangers and joint bookrunners, Xxxxxxx Xxxxx Credit Partners L.P., as syndication agent, and General Electric Capital Corporation, Natixis and The Royal Bank of Scotland plc, as documentation agents.

B. Capitalized terms used herein and not otherwise defined herein shall have the meanings assigned to such terms in the Credit Agreement and the Security Agreement referred to therein.

C. The Grantors have entered into the Security Agreement in order to induce (i) the Lenders to make Loans and the L/C Issuers to issue Letters of Credit, (ii) the Hedge Banks to enter into and/or maintain Secured Hedge Agreements and (iii) the Cash Management Banks to provide Cash Management Services. Section 6.12 of the Security Agreement provides that additional Restricted Subsidiaries of the Borrower may become Grantors under the Security Agreement by execution and delivery of an instrument in the form of this Supplement. The undersigned Restricted Subsidiary (the “New Subsidiary”) is executing this Supplement in accordance with the requirements of the Credit Agreement to become a Grantor under the Security Agreement in order to induce (A) the Lenders to make additional Loans and the L/C Issuers to issue additional Letters of Credit, (B) the Hedge Banks to enter into and/or maintain Secured Hedge Agreements and (C) the Cash Management Banks to provide Cash Management Services and as consideration for (x) Loans previously made and Letters of Credit previously issued, (y) Secured Hedge Agreements previously entered into and/or maintained and (z) Cash Management Services previously provided.

Accordingly, the Administrative Agent and the New Subsidiary agree as follows:

SECTION 1. In accordance with Section 6.12 of the Security Agreement, the New Subsidiary by its signature below becomes a Grantor under the Security Agreement with the same force and effect as if originally named therein as a Grantor and the New Subsidiary hereby (a) agrees to all the terms and provisions of the Security Agreement applicable to it as a Grantor thereunder and (b) represents and warrants that the representations and warranties made by it as a Grantor thereunder are true and correct on and as of the date hereof. In furtherance of the foregoing, the New Subsidiary, as security for the payment in full of the Obligations does hereby create and grant to the Administrative Agent, its successors and assigns, for the benefit of

the Secured Parties, their successors and assigns, a security interest in and lien on all of the New Subsidiary’s right, title and interest in and to the Collateral (as defined in the Security Agreement) of the New Subsidiary. Each reference to a “Grantor” in the Security Agreement shall be deemed to include the New Subsidiary. The Security Agreement is hereby incorporated herein by reference.

SECTION 2. The New Subsidiary represents and warrants to the Administrative Agent and the other Secured Parties that this Supplement has been duly authorized, executed and delivered by it and constitutes its legal, valid and binding obligation, enforceable against it in accordance with its terms, except as such enforceability may be limited by Debtor Relief Laws and by general principles of equity.

SECTION 3. This Supplement may be executed in counterparts (and by different parties hereto on different counterparts), each of which shall constitute an original, but all of which when taken together shall constitute a single contract. This Supplement shall become effective when the Administrative Agent shall have received a counterpart of this Supplement that bears the signature of the New Subsidiary, and the Administrative Agent has executed a counterpart hereof. Delivery of an executed signature page to this Supplement by facsimile transmission or other electronic communication shall be as effective as delivery of a manually signed counterpart of this Supplement.

SECTION 4. The New Subsidiary hereby represents and warrants that (a) set forth on Schedule I attached hereto is a true and correct schedule of the location of any and all Collateral of the New Subsidiary and (b) set forth under its signature hereto is the true and correct legal name of the New Subsidiary, its jurisdiction of formation, the location of its chief executive office and its organizational identification number. Schedule I shall be incorporated into, and after the date hereof be deemed part of, the Perfection Certificate.

SECTION 5. Except as expressly supplemented hereby, the Security Agreement shall remain in full force and effect.

SECTION 6. THIS SUPPLEMENT SHALL BE GOVERNED BY, AND CONSTRUED IN ACCORDANCE WITH, THE LAWS OF THE STATE OF NEW YORK.

SECTION 7. If any provision of this Supplement is held to be illegal, invalid or unenforceable, the legality, validity and enforceability of the remaining provisions of this Supplement shall not be affected or impaired thereby. The invalidity of a provision in a particular jurisdiction shall not invalidate or render unenforceable such provision in any other jurisdiction.

SECTION 8. All communications and notices hereunder shall be in writing and given as provided in Section 6.01 of the Security Agreement.

SECTION 9. The New Subsidiary agrees to reimburse the Administrative Agent for its reasonable out-of-pocket expenses in connection with this Supplement, including the reasonable fees, other charges and disbursements of counsel for the Administrative Agent.

[Signatures on following page]

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IN WITNESS WHEREOF, the New Subsidiary and the Administrative Agent have duly executed this Supplement to the Security Agreement as of the day and year first above written.

SCA SURGERY HOLDINGS, LLC
By:		/s/ Xxxxxxx X. Xxxxxx, Xx.
		Name: Xxxxxxx X. Xxxxxx, Xx.
		Title: Vice President and Secretary

Jurisdiction of Formation: Delaware Organizational Identification Number: # 4545056 Address of Chief Executive Office: 0000 Xxxxxxxxxx Xxxxxxxx Xxxxx 000 Xxxxxxxxxx, XX 00000
JPMORGAN CHASE BANK, N.A.,     as Administrative Agent
By:		/s/ Xxxx XxxXxx
		Name: Xxxx XxxXxx
		Title: Executive Director

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SCHEDULE I

LOCATION OF COLLATERAL

Description		Location
Equity Interests, as described below.		0000 Xxxxxxxxxx Xxxxxxxx
		Xxxxx 000
		Xxxxxxxxxx, XX 00000

EQUITY INTERESTS

Issuer		Number of Certificate		Registered Owner		Number and Class of Equity Interests		Percentage of Equity  Interests
Marin Surgery Holdings, Inc.		Number 1		SCA Surgery Holdings, LLC		1,000 shares of Common Stock			100	%
Surgical Hospital Holdings of Oklahoma, LLC		N/A – uncertificated		SCA Surgery Holdings, LLC		100% membership interests			100	%
Lakeside Surgery Holdings, Inc.		Number 1		SCA Surgery Holdings, LLC		1,000 shares of Common Stock			100	%
SCA Holding Company, Inc.		Number 1		SCA Surgery Holdings, LLC		1,000 shares of Common Stock			100	%
San Leandro Surgery Holdings, Inc.		Number 1		SCA Surgery Holdings, LLC		1,000 shares of Common Stock			100	%
Mississippi Surgery Holdings, LLC		N/A – uncertificated		SCA Surgery Holdings, LLC		100% membership interests			100	%
West Coast Endoscopy Holdings, LLC		N/A – uncertificated		SCA Surgery Holdings, LLC		100% membership interests			100	%

DEBT SECURITIES

Issuer		Principal Amount		Date of Note		Maturity Date
N/A		N/A		N/A		N/A

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