PURPOSE: To attempt to quantitate the carbon footprint of minimally invasive surgery (MIS) through approximated scope 1 to 3 CO(2) emissions to identify its potential role in global warming. PATIENTS and METHODS: To estimate national usage, we determined the number of inpatient and outpatient MIS procedures using International Classification of Diseases, ninth revision-clinical modification codes for all MIS procedures in a 2009 sample collected in national databases. Need for surgery was considered essential, and therefore traditional open surgery was used as the comparator. Scope 1 (direct) CO(2) emissions resulting from CO(2) gas used for insufflation were based on both escaping procedural CO(2) and metabolic CO(2) eliminated via respiration. Scopes 2 and 3 (indirect) emissions related to capture, compression, and transportation of CO(2) to hospitals and the disposal of single-use equipment not used in open surgery were calculated. RESULTS: The total CO(2) emissions were calculated to be 355,924 tonnes/year. For perspective, if MIS in the United States was considered a country, it would rank 189 th on the United Nations 2008 list of countries' carbon emissions per year. Limitations include the inability to account for uncertainty using the various models and tools for approximating CO(2) emissions. CONCLUSION: CO(2) emission of MIS in the United States may have a significant environmental impact. This is the first attempt to quantify CO(2) emissions related to MIS in the United States. Strategies for reduction, while maintaining high quality medical care, should be considered.