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BACKGROUND: Nonagenarians are the fastest growing sector of population across Western Europe, Although prevalence of gall bladder disease is high, elective cholecystectomy is still controversial in this age group. METHODS: A retrospective chart review was conducted of cholecystectomies done in patients over 90 years of age at our institution between 2004 and December 2009. During this period, a total of 3,007 cholecystectomies were performed on patients of all ages. Data collected included demographics, patient co-morbidities, indications for surgery, type of surgery performed, intraoperative findings, histology, perioperative morbidity and mortality. RESULTS: Twenty-two nonagenarians (19 females) underwent cholecystectomy during the study period. Of these patients, 8 (33%) had diabetes, 12 (50%) had hypertension, and 10 (42%) had coronary artery disease. Nineteen patients (86%) underwent an emergency procedure. In one patient cholecystectomy was indicated for non-resolving pain after attempted conservative therapy, only two patients were operated electively. Laparoscopic cholecystectomy was attempted in 13 patients (59%), 3 patients needed a conversion, and 8 patients (36%) considered unfit to undergo a laparoscopic approach had an open procedure. Mean operation time was 71 minutes. Histology showed gangrenous cholecystitis in 14 (64%) patients. The mean length of stay was 10 days (4-23d). Two patients (9%) required intensive care following surgery. There were no common bile duct injuries, one patient had a cystic stump leak. One patient died in the postoperative period (4.5%). All patients with an emergency operation were classified as at least ASA III. Conversion rate, percentage of open procedures, percentage of advanced histology, ASA-score and hospital stay were significantly higher when compared to all patients. CONCLUSION: Our study demonstrates that in unselected nonagenarians,cholecystectomy is safe with acceptable perioperative morbidity and mortality even as an emergency procedure. However, our data also suggests that cholecystitis appears to be a neglected condition in this age group. Elective cholecystectomy should be considered even in the very elderly.