The single biggest predictor of how well you recover from surgery isn’t the operation itself — it’s how you prepare for it in the four weeks before.
For most of medical history, surgeons told patients the same thing before an operation: “Eat well, rest well, and stop everything.” That advice is now outdated.
The 2025 update of the Enhanced Recovery After Surgery (ERAS) Society guidelines, together with the latest preoperative recommendations from the American Society of Anesthesiologists (ASA) and the American Diabetes Association (ADA), have flipped the script. The new global standard is prehabilitation — actively conditioning the body in the weeks leading up to surgery, the same way an athlete trains for a competition.
The evidence is striking. Structured pre-operative optimization can cut post-operative complications by nearly 50%, shrink hospital stays, and significantly speed up the return to normal life. Yet in routine Indian surgical practice, most patients still walk into the operating theatre under-optimized — uncontrolled diabetes, untreated anaemia, last-night gutka, undisclosed Ozempic, no exercise reserve.
This guide is what I tell every patient in my own clinic before any elective laparoscopic or robotic surgery. It is built around the seven pillars of prehabilitation, all grounded in 2024–2025 international evidence and adapted for the realities of patients in Hyderabad and across India.
What Is Prehabilitation?
Prehabilitation (or “prehab”) is the structured medical preparation a patient undergoes in the weeks before surgery to maximize their physical, nutritional, and psychological reserve. Originally developed for major cancer surgery, it is now considered the standard of care for almost all elective procedures — from gallbladder and hernia surgery to bariatric, colorectal, and oncologic operations.
It is not a single pill, a herbal tonic, or an “immunity booster.” It is a coordinated 4-to-8-week programme covering nutrition, exercise, glycaemic control, anaemia correction, smoking and alcohol cessation, mental preparation, and medication review. The earlier you start, the greater the benefit.
The 7 Pillars of Pre-Operative Optimization
1. Nutrition — Especially Protein
Between 30% and 65% of patients undergoing major surgery are malnourished, particularly those with cancer, chronic gastrointestinal disease, or significant comorbidities. Inadequate protein is the single biggest unmet nutritional gap — and it directly delays wound healing while doubling the risk of post-operative infection.
The latest European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines recommend 1.2 to 1.5 grams of protein per kilogram of body weight per day, starting at least 2 to 4 weeks before surgery. For a 70 kg adult, that translates to roughly 85 to 105 grams of protein daily.
Practical Indian sources: eggs, dal (especially moong and toor), paneer, milk and curd, soya chunks, chicken, fish. A validated nutritional screen — MUST (Malnutrition Universal Screening Tool) or NRS-2002 (Nutritional Risk Screening) — should be done at the first pre-op consultation. If risk is identified, supplementation (oral nutritional supplements, in severe cases parenteral nutrition) may be added.
2. Correcting Anaemia Before Surgery
Anaemia is highly prevalent in the Indian population — especially among women of reproductive age, vegetarians, and patients with chronic disease. Operating on a patient with low haemoglobin almost always means a blood transfusion, slower wound healing, and a longer recovery.
The UK Centre for Perioperative Care (CPOC) March 2025 guideline is unambiguous: if pre-operative haemoglobin is below 12 g/dL, the patient should receive intravenous (IV) iron infusion rather than oral iron tablets. IV iron is faster, more reliable, and bypasses the gut absorption issues that limit tablets. The minimum lead time is 2 weeks before surgery for haemoglobin to rise meaningfully — which is why anaemia must be flagged early.
If your haemoglobin is below 10 g/dL and your surgery is more than four weeks away, ask your surgeon about IV iron at your very first consultation.
3. Glycaemic Control — HbA1c Below 8%
Uncontrolled diabetes delays wound healing, doubles the risk of surgical site infection, and increases the chance of major cardiac and renal complications during anaesthesia.
The American Diabetes Association 2026 Standards of Care set the elective-surgery target at HbA1c below 8%. For patients using a continuous glucose monitor (CGM), the equivalent metric is time-in-range above 50% over the preceding 14 days.
An important caveat: surgery should not be unnecessarily postponed for HbA1c alone. If the operation is urgent — for example, an acute gallbladder, an obstructive cancer, or an acute hernia — it must proceed with optimized perioperative insulin protocols. The HbA1c target is for elective, scheduled surgery where there is time to optimize.
4. Tobacco and Alcohol — Stop for at Least 4 Weeks
Nicotine constricts small blood vessels and reduces the oxygen and blood supply that a healing wound depends on. Stopping smoking 4 weeks before surgery cuts the risk of post-operative wound infection by nearly half — a finding consistent across the most recent 2024 systematic review of preoperative smoking cessation.
A critical point that’s almost always overlooked in Indian surgical practice: gutka, khaini, paan, and any chewed smokeless tobacco cause exactly the same wound-healing damage as cigarettes. Patients who say “I don’t smoke, doctor — I only chew” are not protected. The vasoconstrictive and cytotoxic effects on healing tissue are well-documented.
Alcohol must also be stopped at least 4 weeks before surgery. Heavy alcohol use impairs the immune response, reduces the liver’s ability to handle anaesthesia and post-op medications, and increases bleeding risk during and after the operation.
5. Exercise & Frailty Screening
The instinct to “rest before a big operation” is one of the most counterproductive things a patient can do. Recent meta-analyses are clear: a simple daily routine, started 4 weeks before surgery, meaningfully reduces post-operative lung complications and the risk of deep vein thrombosis (DVT).
What I recommend to my patients:
- 30 minutes of brisk walking, every day
- 10 minutes of breathing exercises using an incentive spirometer (available at any chemist for under ₹500)
- Stair-climbing, if physically possible, as a simple cardiovascular conditioner
For patients over the age of 65, a formal frailty screen — the Clinical Frailty Scale, grip-strength testing, or the Timed Up-and-Go test — is now standard. If frailty is detected, a tailored prehab plan with targeted nutrition and physiotherapy can restore meaningful function before surgery. This applies especially to older patients undergoing cancer surgery, orthopaedic surgery, or any major abdominal operation.
6. Psychological Preparation
Approximately 60% of patients experience clinically significant anxiety before surgery — and that anxiety is not “just nerves.” It directly worsens post-operative pain, nausea, insomnia, and even the inflammatory response that drives some complications.
What helps, and what the 2024 evidence supports:
- A detailed pre-op conversation with your surgeon — every question answered, every step explained
- Watching reliable patient-education videos from credentialed surgeons (avoid unverified social media content, which often increases anxiety)
- Bringing a family member into the consultation
- Daily slow breathing or guided meditation — even 10 minutes
If you have persistent anxiety, depression, or unresolved trauma related to a previous hospital experience, mention it to your surgeon. It is not a weakness — it is clinically relevant information.
7. Medication Review — The Pillar Most Patients Get Wrong
Tell your surgeon every single medication, supplement, and injection you take. Including the ones you “only take sometimes” and the ones a relative or pharmacist recommended.
A few categories deserve particular attention in 2025–2026:
- GLP-1 receptor agonists — Ozempic, Wegovy, Mounjaro, Rybelsus, Saxenda. These weight-loss and diabetes injections slow stomach emptying and create a real risk of food being aspirated into the lungs during anaesthesia. The 2024 ASA consensus guidance recommends holding weekly GLP-1 injections for one full week before surgery, and daily forms on the day of surgery.
- Direct oral anticoagulants (DOACs) — Apixaban (Eliquis), Rivaroxaban (Xarelto), Dabigatran (Pradaxa). Per the 2024 American College of Chest Physicians (ACCP) guidance, these no longer require “bridging” heparin injections in most patients. They are simply held for 1 to 2 days before surgery and resumed 24 to 72 hours after.
- Antiplatelet medications — Aspirin and Clopidogrel decisions are individualized based on why you’re taking them (recent stent, prior stroke, etc.). Never stop these on your own — always with your surgeon and cardiologist together.
- Herbal supplements — Garlic capsules, ginkgo, ginseng, fish oil, and ashwagandha can all increase bleeding risk. Stop them 1 to 2 weeks before surgery.
Two Outdated Beliefs to Drop
“No food or water from midnight before surgery”
This is the single most outdated piece of pre-operative advice still in routine use. The current ASA guidelines explicitly allow clear carbohydrate-containing drinks up to 2 hours before surgery. A 2025 meta-analysis confirmed that this practice reduces post-operative thirst, nausea, insulin resistance, and overall hospital length of stay. Solid food is still avoided for 6 to 8 hours pre-op, and dairy is treated as a solid — but carbohydrate drinks (oral rehydration solution, clear juice without pulp, sweet black tea or coffee without milk) are not only safe but actively recommended.
“A big surgery needs every test in the book”
Battery testing — chest X-ray, ECG, echocardiography, pulmonary function tests, full coagulation profile — without a specific indication is no longer considered good practice. Modern pre-operative evaluation is risk-stratified: the surgeon and anaesthetist decide which tests are genuinely needed based on your age, comorbidities, and the planned operation. Unnecessary tests delay surgery, generate incidental findings that lead to more tests, and inflate cost with no benefit. If you have been asked for an investigation that you don’t understand, ask why.
When Should You Start Prehabilitation?
The earlier the better. The minimum useful window is 4 weeks before surgery; ideal is 6 to 8 weeks for major procedures (cancer surgery, bariatric surgery, complex hernia repair, joint replacement). If your surgery is in 7 days, prehab benefits are limited but not zero — focus on hydration, carbohydrate loading, smoking cessation, mental preparation, and medication review.
A formal pre-operative optimization consultation typically includes a structured nutritional screen, a baseline blood panel including haemoglobin, ferritin and HbA1c, a frailty assessment if you are over 65, a medication review, and a personalized 4-week plan that covers each of the seven pillars described above.
5 Questions to Ask Your Surgeon Before Surgery
- Do I need a prehabilitation programme — and if so, who will coordinate it?
- Are my haemoglobin, blood sugar, and other key labs fit for surgery? If not, what is the optimization plan?
- Which of my current medications should I stop, and exactly when?
- How long must I fast before the surgery — and can I have a clear carbohydrate drink up to 2 hours before?
- How much daily protein and how much daily exercise should I aim for, starting now?
Frequently Asked Questions
How many weeks before surgery should I stop smoking?
At least 4 weeks. A 2024 systematic review showed 4-week cessation cuts wound infection risk by nearly 50%. This includes gutka, khaini, and all forms of chewed tobacco.
Can I drink water before surgery?
Yes. Modern ASA guidelines allow clear carbohydrate drinks up to 2 hours before surgery. The old “nothing from midnight” rule is outdated and worsens post-op nausea and insulin resistance.
Do I need to stop Ozempic or Mounjaro before surgery?
Yes. Weekly GLP-1 injections must be stopped one full week before surgery (ASA 2024 guidance). Otherwise, food retained in the stomach can be aspirated into the lungs during anaesthesia.
What HbA1c level is safe for elective surgery?
Below 8%, per the ADA 2026 Standards of Care. CGM users should target time-in-range above 50%. Urgent surgeries should not be postponed for HbA1c alone.
Should I take iron tablets before surgery if I’m anaemic?
If your haemoglobin is below 12 g/dL, intravenous iron infusion is now preferred over tablets (UK CPOC 2025). IV iron is faster, more reliable, and works in 2 weeks.
How much protein should I eat before surgery?
1.2 to 1.5 grams per kilogram of body weight per day, starting 2 to 4 weeks before surgery. For a 70 kg adult, that’s 85 to 105 grams daily — eggs, dal, paneer, milk, chicken, fish.
The Bottom Line
Surgery is a partnership. The success of an operation does not rest on the surgeon’s hands alone — your own preparation in the four to eight weeks before matters just as much, and often more. The seven pillars are simple, evidence-based, and within reach of every patient who is willing to invest in them.
If you have a surgery coming up — yours, or anyone you love — start the conversation early. The earlier you optimize, the better your outcome.
Your health is in your hands.
Evidence base & references
- ERAS Society Colorectal Surgery Guidelines 2025
- American Society of Anesthesiologists Consensus Guidance on GLP-1 Receptor Agonists (2024)
- Multi-society clinical practice guidance for safe use of GLP-1 receptor agonists in the perioperative period (PMC, 2024)
- UK Centre for Perioperative Care — Guideline for the Management of Anaemia in the Perioperative Pathway (March 2025)
- American Diabetes Association — Standards of Care in Diabetes 2026, Chapter 16 (Diabetes Care in the Hospital)
- ESPEN Practical Guideline: Clinical Nutrition in Surgery
- Multimodal prehabilitation meta-analysis (Cureus, 2025)
- Preoperative smoking cessation interventions — systematic review and meta-analysis (Updates in Surgery, 2025)
- Comprehensive geriatric assessment, frailty and sarcopenia in elderly surgical patients — narrative review (SAGE, 2025)
- Preoperative carbohydrate loading reduces length of stay after major elective non-cardiac surgery (Scientific Reports, 2025)
- American College of Chest Physicians (ACCP) — Perioperative Management of DOACs (2024)
Dr. Sujeeth Kumar Bashetty
MBBS · MS (General Surgery) · FIAGES · FAIS · FALS · DIPMAS · FICRS
Professor & Senior Consultant — Laparoscopic & Robotic Surgeon, Apollo Hospitals, Jubilee Hills, Hyderabad. 20+ years of surgical experience across hernia, gallbladder, GI, thyroid, colorectal, bariatric and robotic surgery. India Today “Top 7 Surgeons — South India 2022.”
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