Background <p>Laparoscopic cholecystectomy(LC)carries significant risks for extremely elderly patients(≥ 80 years of age).The Enhanced Recovery After Surgery(ERAS)protocol aims to mitigate surgical stress through optimized perioperative management, offering potential protection for this patient population.</p> Case summary <p>A 101-year-old female patient was admitted with “abdominal pain, chills, and fever for 9 hours,” diagnosed with gallstones complicated by acute suppurative cholecystitis. She had multiple underlying conditions, including severe pulmonary hypertension and severe malnutrition, as well as a history of femoral head replacement surgery.</p> Methods and results <p>After multidisciplinary team (MDT) evaluation, laparoscopic cholecystectomy was performed with intraoperative hypobaric pneumoperitoneum (8–10 mmHg) to minimize cardiopulmonary impact. An individualized ERAS protocol was implemented perioperatively, including oral intake within 2&#xa0;h postoperatively, ambulation within 36&#xa0;h, and precise fluid and nutritional support. The patient recovered uneventfully without major complications and was discharged in good condition 10 days postoperatively. A 90-day follow-up showed that the patient’s Activities of Daily Living (ADL) score improved from 35 to 80 points at discharge, successfully achieving baseline functional levels prior to illness, with no biliary-related complications.</p> Conclusion <p>This case demonstrates that laparoscopic cholecystectomy is safe and feasible for strictly screened elderly patients with acute biliary emergencies under multidisciplinary collaboration and individualized ERAS management. Advanced age should not be an absolute contraindication for surgery. The core of clinical success lies in the precise assessment of patients’ “physiological resilience” and the implementation of individualized ERAS pathway adjustments for the ultra-elderly population.</p>