Significant recent interest has focussed on improving outcomes after emergency laparotomy. This retrospective database analysis estimated the annual incidence and associated inpatient costs of emergency laparotomy in England. Demographic, process and outcome data were collected for all patients undergoing emergency laparotomy in Brighton for two calendar years (2009–2010). Cost analysis assumed £16 per minute theatre time, and £282 per day ward bed and £1382 per day critical care bed costs. National incidence was confirmed from Hospital Episode Statistics and Office of National Statistics mid-year population data. In total, 768 patients underwent 850 emergency laparotomies. The incidence of emergency laparotomy was estimated as ∼1:1100 population. Thirty-six percent (276 patients) were admitted for a median (IQR [range]) of 5 (3–11 [1–76]) days of critical care. Postoperative median (IQR [range]) length of stay was 13 (8–24 [1–176]) days. Our estimated annual inpatient cost of emergency laparotomy for Brighton was ∼£5 million, equivalent to ∼£13 000 per patient, and for England, an annual estimated cost of ∼£650 million. However, ‘Payment by Results’ reimbursement amounted to a mean (SD) hospital income of just £6905 (2639) per patient, a net financial loss of ∼£6100 per patient, equivalent to a reimbursement shortfall nationally of ∼£300 million. We also found that patients > 70 years (46%) had significantly higher 30-day postoperative mortality (18% vs 6%, p < 0.0001), significantly prolonged median (IQR [range]) length of stay (15 (10–26 [1–123]) days vs 12 (7–22 [1–176]) days, p < 0.001) and incurred higher costs (median (IQR [range]) £9667 (6620–15 732 [1920–103 624]) vs £7467 (4975–14 251 [1178–118 060]), p < 0.001). Emergency laparotomy is a common procedure associated with considerable cost, particularly among elderly patients. A National Emergency Laparotomy Database will help provide an evidence base on which to improve clinical outcome and cost efficiency.