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Background: Gallbladder lesions identified on ultrasound often prompt surgical interventions due to risk of malignancy. Patients are often subjected to an open cholecystectomy rather than a laparoscopic cholecystectomy. Our aim is to describe a large contemporary series of patients who underwent cholecystectomy for gallbladder masses identified on “modern” ultrasound imaging. Methods: Retrospective review of patients who underwent a gallbladder ultrasound and were diagnosed with a polyp or mass between 2/2000-12/2008. Available ultrasound images were reviewed. Results: Overall 201 patients were explored for a pre-operative diagnosis of a gallbladder mass or polyp identified on ultrasound. On final pathology 117 patients (64%) had no apparent mass, 32 patients(17%) had a benign adenomyoma, 21 patients had a polyp of various types (11%; 3 of them were malignant) and 13 patients (7%) had an invasive adenocarcinoma. Patients with adenocarcinoma had a median US size of 34mm(9-38.9). On univariate analysis predictors of malignancy were a size>10mm(p<0.001), irregular gallbladder margin on ultrasound(p<0.001), presence of invasion at the liver interface (p<0.001) and wall thickening(p<0.001) whereas factors such as shape (sessile or penduculated), echogenicity (echogenic or isoechoic) or presence of flow on Doppler did not differ significantly between malignant and benign cases. Among the patients who were resected 124 patients had no mass identified on final pathology. For these patients 26% had a presumptive mass>10mm and 3% had a mass >30mm, 11% had a thickened wall, 1.6% had irregular margins but none had evidence of invasion. Among the 52 patients with a preoperative lesion of less than 5mm 42(81%) patients had no mass, 6(11%) patients had a polyp, and 4(8%) patients had an adenomyoma. Conclusions: Mass like lesions in the gallbladder identified on ultrasound continue to present a clinical dilemma. The development of a risk score for malignancy based on suspicious characteristics such as size>10mm, irregular GB margin, presence of invasion and wall thickening will allow patients to undergo further diagnostic studies.