Among obese patients, especially among those with extreme obesity (body mass index ≥50 kg/m²) who are scheduled for metabolic and bariatric surgery (MBS), obstructive sleep apnea (OSA) is one of the most common and s critical comorbidities, with a prevalence ranging from 35.0% to 93.6% in the bariatric population. MBS is the only treatment method capable of providing long-term effective relief for extreme obesity while alleviating OSA symptoms. However, OSA significantly increases the perioperative respiratory and cardiovascular complications and mortality rates associated with MBS. To reduce perioperative risks associated with MBS, key measures for the perioperative management of OSA involve timely and accurate diagnosis and assessment based on a multidisciplinary team (MDT) collaboration. This includes integrating OSA diagnosis, treatment, and monitoring into the perioperative management process of MBS, standardizing personalized precision treatment. This article, drawing on relevant literature and clinical experience from the authors' institution, introduces the perioperative management process for extreme obesity complicated by OSA, covering preoperative, intraoperative, and postoperative aspects, so as to provide clues and insights for the precise assessment of the most effective and safe treatment options.