Background: Adequate fluid balance before, during and after surgery may reduce morbidity. This review examines current concepts surrounding fluid management in major elective surgery. Method: A narrative review was undertaken following a PubMed search for English language reports published before July 2019 using the terms ‘surgery’, ‘fluids’, ‘fluid therapy’, ‘colloids’, ‘crystalloids’, ‘albumin’, ‘starch’, ‘saline’, ‘gelatin’ and ‘goal directed therapy’. Additional reports were identified by examining the reference lists of selected articles. Results: Fluid therapy is a cornerstone of the haemodynamic management of patients undergoing major elective surgery. Both fluid overload and hypovolaemia are deleterious during the perioperative phase. Zero-balance fluid therapy should be aimed for. In high-risk patients, individualized haemodynamic management should be titrated through the use of goal-directed therapy. The optimal type of fluid to be administered during major surgery remains to be determined. Conclusion: Perioperative fluid management is a key challenge during major surgery. Individualized volume optimization by means of goal-directed therapy is warranted during high-risk surgery. In most patients, balanced crystalloids are the first choice of fluids to be used in the operating theatre. Additional research on the optimal type of fluid for use during major surgery is needed. © 2020 BJS Society Ltd Published by John Wiley & Sons Ltd