Background. Historically, the operative mortality associated with hepatic abscess was > 50%. More recently, patients have been treated with percutaneous drainage; however, those failing conservative management are treated operatively. Our aim was to evaluate the outcome of operation for hepatic abscess in those failing conservative treatment or in those presenting as a surgical emergency. Patients and methods. This was a retrospective review of patients undergoing operation for hepatic abscess at the Mayo Clinic, Rochester, Minnesota from 1990 to 2003. Results. Of 288 patients diagnosed with hepatic abscesses, 32 required operation. Percutaneous drainage was the initial treatment in 15 (47%). The remaining 17 were initially managed with operation. Operative indication was septic shock (41%), failed nonoperative management (31%), and failure to make a diagnosis (28%). Operation was drainage (62%) or resection (38%). The morbidity and mortality rates were 41% and 15.6%, respectively. Factors associated with increased operative mortality were shock (p =0.04), INR > 1.5 (p =0.03), WBC > 15 000 (p =0.04), AST > 150 U/L (p =0.01), alkaline phosphatase > 500 U/L (p =0.03), positive blood cultures (p =0.03), total bilirubin > 2.0 mg/dl (p < 0.01), multiple abscesses (p =0.01), and second operation (p <0.001). Factors not associated were extent of resection (p > 0.10), peritonitis (p > 0.10), intensive care admission (p > 0.10), polymicrobial infection (p > 0.10), and blood transfusion (p > 0.10). Conclusion. Operative intervention is avoided in 89% of patients with hepatic abscess. Septic shock is the most common reason for operation. Patients with septic shock, INR > 1.5, WBC > 15 000, AST > 150 U/L, total bilirubin > 2.0 mg/dl, positive blood cultures, or alkaline phosphatase > 500 U/L have increased mortality when undergoing operation for hepatic abscess. © 2006 Taylor & Francis.