The obesity epidemic has resulted in the premature onset of traditionally adult diseases in children and adolescents. Bariatric surgery can be used to achieve significant weight loss and resolution of major and minor comorbidities of obesity. It is not known, however, whether weight loss or comorbidity resolution after adolescent bariatric surgery is sustainable over the lifetime, given the powerful biologic mechanisms that are thought to play an important role in development of severe obesity in these patients. There are also concerns about whether bariatric procedures may have unanticipated adverse nutritional consequences when applied in adolescence. Principles of adolescent medicine and evidence from adult bariatric surgical studies can be used to rationally guide the application of bariatric procedures to a group of young patients wither serious medical and psychological comorbidities of severe obesity. Given the immediacy of some of the medical and psychosocial complications, impaired quality of life, and the added health care costs of adolescent obesity, adolescent bariatric surgery programs should be developed to meet these needs. Adolescent bariatric surgery programs should have expertise that enables them to assess and meet the unique medical, cognitive, physiological, and psychosocial needs of the adolescent. Indications for operation during adolescence should be conservative until appropriately designed clinical studies have demonstrated the safety and efficacy of these techniques applied to adolescents.