The concept and the role of emergency general surgery (EGS) has progressively evolved over the last decades, and dedicated pathways are required for EGS, similarly to what has already been established for trauma. EGS patients, together with trauma patients, represent 20% of inpatient population in the USA, and 25% of inpatient costs. These patients have a high rate of health care utilization, higher mortality rates and longer hospital stay. International guidelines and current evidences show that organizational models improve the outcome of the patients in the EGS setting. The cornerstones of a structured and effective EGS organizational model are surgical expertise, quick decision making, organizational performance and clinical competence. There is a strong need for dedicated and “subspecialist” emergency surgeons. At the same time, emergency surgeons should be inserted in an effective system with the ability to be continuously enhanced and improved. The organization of such a dedicated system will improve the level of competence in the management of surgical emergency, guaranteeing to a vast amount of population an emergency surgical service with high skills, knowledge and a guidelines-guided treatment.