Surgeons continuously work to ensure that their patients receive safe, timely and high-quality care, often in challenging circumstances. The strive for excellence may often manifest itself in the surgeons’ obsessive pursuit for technical perfection with focus on minute details of the procedure itself. Despite the efforts, adverse events still occur, leading to suboptimal results for patients and sometimes to fatal outcomes. A high global variation in post-operative mortality exist after both elective and emergency surgery [1, 2], across clinical pathways and for specific procedures [3].

Most elective surgical procedures have a very low risk for death, mortality as an outcome metric is most reliably used in situations or for conditions with high stakes and high risks involved. Patients present with emergency conditions for which surgeons are expected to lead a team in diagnostic work up to make the right decisions for best management. For emergency surgery, the risk of death increases several-fold compared to similar elective surgery (e.g. elective abdominal aortic aneurysm repair compared to ruptured abdominal aortic aneurysm), with persistent and in part unexplained variation in the mortality reported across and within health care systems.

Even though surgical technical details are important and not to be neglected, the outcome after surgery depends just as much on other attributes to surgery as the mere technical performance of the procedure. Thus, a hypothetical framework to build a “formula for survival in surgery” is presented to allow for dedicated quality-improvement on safety elements to surgery with the aim to improve survival.