Objective: To assess the determinants of referred patients for emergency surgical operation from second level hospitals to tertiary level hospital (MNH) in Dar es Salaam region, many surgical patients with surgical emergency conditions are referred to tertiary level hospitals; little information is documented for the determinants of referral of general surgery patients for emergency operations, instead of patients being operated at second level hospitals. Methodology: The study design was cross-sectional descriptive hospital-based study, conducted at emergency department of MNH in period of five months, from June – October, 2013. A total of 363 patients were referred from second level hospital to tertiary level hospital in Dar es Salaam region during the study period. Results: The determinants grouped into four main groups and several small sub groups in each main group. The main groups include type of Disease/diagnosis, Shortage or lack of medical personnel, Shortage or lack of equipment in the theatre and at the laboratory, and lastly the insufficient infrastructures. The data analysis showed that the majority of the referred patients require emergency surgical operations. The total of 363 patients referred, 62.5% of patients required urgent attention and the remaining 37.5% were cold cases. The musculoskeletal conditions was the leading referral disease 50.7%, about half of all referrals, followed by gastrointestinal diseases 26.7% and then neurological disease 11.3%. Lack or shortage of the health personnel were as follows; The leading shortage of personnel was about 36.6% referrals was due to the shortage of General Surgeons, 29.8% due to shortage of Orthopaedic Surgeons and 15.15% referrals due to shortage of Neurosurgeons. The leading factor in lack of equipment was lack of investigation services about 33.3% referrals, lack of sterile gauze at the operating theatre was about 24.8% and lack of sterile trays for surgeries was about 18.5%. The leading factor in