Minimally invasive surgery is an important strategy to reduce the metabolic impact of surgery and improve recovery. However, there are multiple other developments outside the traditional of the surgeon that may have a large impact on the surgical stress response and ultimately on outcomes. These include afferent neural blockade, pharmacologic interventions, fluid management, psychological preparation, exercise and nutritional interventions. Guidelines from the ERAS® Society on optimal perioperative management include over 20 evidence-based interventions that have been shown to improve outcomes. Most are “strong” recommendations, meaning they are supported by high-level evidence. They involve the entire trajectory of surgical care, preoperative, intraoperative, and postoperative, and all stakeholders—patients, nurses, anesthesiologists, surgeons, and other team members. Several recommendations challenge tightly held surgical traditions around drain management, bowel preparation, intravenous fluids, and fasting. Enhanced recovery pathways, as described in this manual, integrate these various interventions into a standardized perioperative care pathway. The goal is to reduce surgical stress, support early return of normal functioning, reduce complications, and ultimately improve full recovery after major surgery. The use of an ERP is associated with reduced hospital stay and 30 % reduction in the risk of overall complications, without increasing mortality, major complications or readmissions. The effects are similar across different surgical disciplines and for laparoscopic and open surgery. The use of laparoscopy facilitates many other elements of an ERP, and the optimal approach is to combine the two. The Enhanced recovery approach is cost-effective compared to conventional perioperative management, even when implementation and management costs are taken into account.