Surgical care in low- and middle-income countries (LMICs) has suffered from insufficient prioritization, especially in rural settings1–۴٫ Low-income countries struggle with an insufficient surgical workforce; the surgical specialist workforce density is 0⋅۷ per 100 000 population5, far below the recommendation1 of 20 per 100 000 population. In addition, surgical facilities and equipment are often inadequate6. The combination of lack of trained personnel and equipment has resulted in a lack of safe and affordable access to surgical care for 90 per cent of patients who need it, contributing to high rates of surgical morbidity and mortality in LMICs1. It is now recognized that surgical care has a central role in the management of many medical conditions1, but little is known about the cost of providing surgical care in LMICs. Because of a history of patients with conditions that need surgical intervention being referred to higher-level hospitals and the perception that higher-level hospitals should provide surgery, surgical care is often viewed as expensive compared with the medical management of other diseases2,3,7. However, a systematic review3 of the cost-effectiveness of surgical care showed that most essential surgical interventions, such as general surgery, caesarean sections and orthopaedic surgery, are cost-effective in LMICs. The Lancet Commission on Global Surgery recommended that caesarean section, laparotomy and open fracture treatment, collectively referred to as the ‘bellwether procedures’, be available to patients at district hospitals1. The bellwether procedures are important to provide timely access to these procedures at district hospitals, but their availability also correlates with a facility’s ability to perform a broad array of other essential surgical services1. However, in sub-Saharan Africa few district hospitals provide laparotomy8, and even fewer estimate its costs9. In Rwanda, the majority (82⋅۵ per cent) of surgical interventions are performed at district hospitals, and over half of these interventions are caesarean sections10. Patients needing a laparotomy or open fracture treatment, however, are commonly referred to tertiary hospitals11. Over the past several years, Rwanda has been intensively training surgical specialists via the Rwanda Human Resources for Health Program12. In addition, the Rwandan Ministry of Health is decentralizing the provision of essential surgical care by establishing provincial hospitals as newly appointed rural referral hospitals13. As the pipeline of trained surgical providers expands to these rural hospitals where surgical infrastructure already exists, the next two procedures to be included in the surgical package are laparotomy and open fracture treatment. Knowing the cost of these procedures at rural African district hospitals is essential for planning for availability of laparotomy and determining the reimbursement package for treatment. The aim of this study was to examine the cost of laparotomy for patients with acute abdominal conditions at a rural district hospital in Rwanda.