The role of surgery in portal hypertension remains a topic of debate. For the past 100 years, various surgical procedures have been used to treat variceal bleeding, refractory ascites, and end-stage liver disease. The past decade has seen significant advances in pharmacotherapy, endoscopy, interventional radiology, and surgery for the management of patients with portal hypertension. Liver transplantation has come of age in the 1990s and is now an accepted therapy for patients with end-stage liver disease. The wide array of management options can complicate the decision making process and defines the need to evaluate these patients fully. Factors such as the aetiology and extent of liver disease, response to prior medical, endoscopic, and other interventional treatments, and possibility of future liver transplantation must be considered. This manuscript will review the history of surgical treatments of portal hypertension, describe the surgical procedures with their advantages and disadvantages, and evaluate their role in the elective and emergent settings.