Abstract Introduction As techniques in laparoscopic cholecystectomy have improved, surgeon experience of open cholecystectomy may be limited. This study examined the current indications for and techniques used in primary open cholecystectomy. Methods Some 3100 consecutive patients undergoing elective or emergency cholecystectomy over a 5-year interval were identified from a prospective surgical audit database. Demographic, diagnostic and procedural data were examined. Results There were 123 (4·0 per cent) primary and 219 (7·4 per cent) converted open cholecystectomies. Some 48·0 and 45·6 per cent of patients in the primary open cholecystectomy and converted groups respectively were men, compared with 24·0 per cent of 2758 who had a successful laparoscopic procedure. Primary open cholecystectomy was employed principally for previous upper abdominal open surgery (22·7 per cent) and emergency operation for general peritonitis (19·5 per cent). The fundus-first approach was employed in 53·7 per cent of primary open procedures and 53·0 per cent of conversions, with subtotal excision in 4·9 and 13·2 per cent respectively. Conclusion Primary open cholecystectomy remains a common procedure in the treatment of gallbladder disease despite the success of laparoscopic cholecystectomy. Successful outcome in difficult cases requires familiarity with specific techniques, exposure to which may be limited in current training programmes.