This chapter dives into the surgical management of empyema, emphasizing the variety of techniques available and their associated risk factors. It explores the different surgical interventions such as lung decortication, pleurectomy, and the use of video-assisted thoracoscopic surgery (VATS), highlighting their efficacy in resolving pleural infections while reducing patient morbidity. The chapter also discusses the importance of risk stratification using the RAPID score, which provides crucial insights into patient outcomes based on renal function, age, infection characteristics, and albumin levels. Furthermore, it examines the significant risk factors influencing surgical outcomes, including the duration of symptoms, microbiological findings, and comorbid conditions. The role of Enhanced Recovery After Surgery (ERAS) protocols in improving clinical outcomes, particularly in complex cases like stage III empyema, is also detailed. By integrating evidence from recent studies, including the 2023 MIST-3 trial, the chapter underscores the importance of individualized patient assessment and the adoption of minimally invasive techniques to optimize recovery. The content provides a comprehensive overview of current surgical approaches, risk factors, and the implementation of ERAS protocols in the effective management of empyema.