India has a large burden of individuals harboring asymptomatic gallstones. Based on Markov model decision and cost analysis, selective and concomitant cholecystectomy is recommended for special indications like hemolytic disorders and stones in endemic areas. Expectant management should be adopted in all others. The evolution of laparoscopy should not alter the indications of cholecystectomy. Since more than 90% patients with asymptomatic gallstones remain clinically “silent”, routine laparoscopic cholecystectomy is not indicated for the vast majority of subjects with asymptomatic cholelithiasis. Although laparoscopic cholecystectomy has become much safer, there remains associated morbidity and mortality. The risks of the operation outweigh the complications if stones are left in-situ. Patients should be counseled about the natural history and available management options, their advantages and disadvantages, and should be part of the decision making process. Prophylactic routine cholecystectomy for asymptomatic stones is not recommended. However, laparoscopic cholecystectomy should be performed selectively or concomitantly in a specific subgroup of patients.