Laparoscopy has been widely adopted in elective abdominal surgery but is still sparsely used in emergency settings. The study investigated the effect of laparoscopic emergency surgery using a population database. Data for all patients from December 2013 to November 2018 were retrieved from the NELA national database of emergency laparotomy for England and Wales. Laparoscopically attempted cases were matched 2 : 1 with open cases for propensity score derived from a logistic regression model for surgical approach; included co-variates were age, gender, predicted mortality risk, and diagnostic, procedural and surgeon variables. Groups were compared for mortality. Secondary endpoints were blood loss and duration of hospital stay. Of 116 920 patients considered, 17 040 underwent laparoscopic surgery. The most common procedures were colectomy, adhesiolysis, washout and perforated ulcer repair. Of these, 11 753 were matched exactly to 23 506 patients who had open surgery. Laparoscopically attempted surgery was associated with lower mortality (6.0 versus 9.1 per cent, P < 0.001), blood loss (less than 100 ml, 64.4 versus 52.0 per cent, P < 0.001), and duration of hospital stay (median 8 (i.q.r. 5-14) versus 10 (7-18) days, P < 0.001). Similar trends were seen when comparing only successful laparoscopic cases with open surgery, and also when comparing cases converted to open surgery with open surgery. In appropriately selected patients, laparoscopy is associated with superior outcomes compared with open emergency surgery.