Obese patients with a body mass index (BMI) ≥50 kg/m² are classified as extreme/super obese. These patients are not only seriously overweight but also complicated by serious obesity-related diseases such as hypertension, diabetes, cardiovascular and cerebrovascular disease, obstructive sleep apnea-hypopnea syndrome (OSAHS) and gastroesophageal reflux disease (GERD). The quality of life and health of extremly obese patients are greatly affected. However, drug therapies have very limited effects on the extremely obese. Bariatric surgeries are the main therapeutic options, but how to select an appropriate surgical procedure is still considerable controversy. First, the safety and smooth-going of the operation should be guaranteed, and the risk factors for perioperative complications should be minimized; secondly, the therapeutic efficacy should be confirmed to help patients to achieve the goals of satisfactory weight loss and improvements of metabolic syndrome; thirdly, existing clinical studies demonstrate that the treatment efficacy in super-obese population is inferior to that in other obese population, so revisional surgical options should be considered before performing the initial surgery. At present, the types of bariatric metabolic surgery are constantly developing and evolving. Each surgical type has its pros and cons because of its different design principles. Sleeve gastrectomy (SG) is the most popular bariatric surgery. It has the advantages of easy operation and relatively fewer postoperative complications but has the disadvantages of limited efficacy for weight loss and glucose-lowering and making no significant improvements in metabolic syndrome. Roux-en-Y gastric bypass (RYGB) is also currently a mainstream operation. It has strong efficacy for weight loss, glucose-lowering, and metabolic improvements, but it has shortcomings, such as complex operations and more postoperative complications. Biliopancreatic diversion duodenal switch (BPD-DS) has the highest efficacy for weight loss and glucose-lowering, but the procedure is most difficult with severe postoperative complications. In recent years, bariatric metabolic surgeons have created a series of modifications focused on the merits and demerits of the above procedures, resulting in many new surgical techniques. Here, the authors analyze and discuss the surgical methods currently recommended by the guidelines and the surgical methods with rapid development, analyze the current controversies and new insights according to the existing clinical evidence, and summarize the significant issues in clinical practice.