Treatment of advanced emphysema is not limited to medical management. Surgical options can also be envisioned for some cases, and physicians must know about them. A bullectomy may be considered for giant bullae, defined by a volume greater than a third of a hemithorax. This option must be discussed even in cases of advanced obstructive disease. Lung volume reduction surgery is useful for emphysema that is heterogeneously distributed but without individual giant bullae. A large-scale controlled study helped to identify its indications and results. The third possible surgical option is lung transplantation. It offers the greatest functional benefits but also involves considerable risks. One of the key points is therefore to define the optimal moment in a patient's life when this option should be discussed. Recent guidelines developed by a panel of international experts provide clinicians with the criteria for considering transplantation.