What is prehab? A complete guide for patients preparing for surgery

For patients, families, and the teams supporting them. From the team behind prehabforsurgery.com.

Margaret, six weeks from surgery

Margaret is 68. Two weeks ago she was told she needs major abdominal surgery for cancer. Her surgery is scheduled for six weeks from now. She’s frightened, she’s tired, and she’s trying to absorb a great deal of complex information at once. Her surgeon mentioned, almost in passing, that there are things she can do in the weeks before the operation to help her recovery – but Margaret left the appointment without a clear sense of what those things are.

She is not alone. Most patients leave the surgical consultation with their attention anchored on the operation itself, not on the weeks before. Few are given a structured plan for those weeks. Most go home and wait. And while they wait, the most useful preparation window of their entire surgical journey quietly closes around them.

Prehabilitation – or prehab – is the structured use of that waiting time. It is not magical, it is not exotic, and it is not optional in the sense that it can be safely ignored. It is the package of physical, nutritional, psychological, medical, lifestyle, and practical work that, done well across the weeks before surgery, measurably improves how the surgery goes and how recovery unfolds. This article is the introduction to it: what prehab is, where it came from, what the evidence actually shows, the six pillars that make it up, what to do if you only have two weeks, how to advocate for yourself, and what a realistic plan looks like.

What prehab is, in plain language

Prehab is the deliberate, structured preparation of a person for an upcoming operation, carried out across the weeks (or sometimes days) between the decision to operate and the operation itself. The aim is to arrive at the operating theatre in the best possible physical, nutritional, psychological, medical, and practical condition — so that the body tolerates the surgery better, complications are fewer, recovery is faster, and the patient regains independence sooner.

It is not the same as rehabilitation. Rehab is what happens AFTER surgery – the physio, the nutritional support, the gradual return to function. Prehab is what happens BEFORE. The two are linked – patients who arrive at theatre well-prepared also tend to engage better with rehab afterwards — but they are different processes, with different timing, different goals, and different teams often involved.

Prehab is also not the same as “getting fit before surgery”. That is one part of it – the physical part – but only one of six. A patient who walks every day but ignores their nutritional state, their anxiety, their poorly-controlled diabetes, their smoking, and their home environment is doing one-sixth of the job. Modern prehab is multimodal by design, and the multimodal version is what works.

Healthcare professional? See our evidence-and-delivery companion article.

Where prehab came from – a short history

The idea that patients should be prepared before surgery is not new. Surgeons have always known that fitter patients do better. What is new – over the last fifteen to twenty years – is the structured, evidence-based, multidisciplinary version of that idea, and the body of research showing how much difference it actually makes.

The story has three threads. The first is the Enhanced Recovery After Surgery (ERAS) movement, which began in colorectal surgery in the late 1990s and revolutionised the post-operative period – early eating, early mobilisation, opioid-sparing analgesia, structured discharge planning. ERAS made it obvious that the pre-operative period had been under-attended to relative to the post-operative period.

The second thread is the gradual recognition that surgical outcomes are powerfully predicted by a patient’s baseline physiological reserve – their cardiorespiratory fitness, their muscle mass, their nutritional state, their mental health, their grip strength. A series of large studies in the 2010s showed that patients with low baseline fitness had materially worse outcomes after major surgery, and – critically – that this risk could be modified.

The third thread is the rapid evolution of healthcare-system thinking. As populations age and complex surgery becomes more common, healthcare systems globally are looking for ways to deliver better outcomes without simply adding more theatre capacity. Prehab is one of the few interventions that improves outcomes, reduces length of stay, reduces complications, and pays for itself within months of implementation. Healthcare systems in the United States, Canada, the United Kingdom, Ireland, Australia, the Netherlands, and many other countries are now investing in formal prehab pathways — though access varies enormously, and many patients still need to drive their own prehab process.

Have we been doing it all along — just calling it something else?

A reasonable question. The honest answer is: no, not really.

What has happened historically is that surgeons would advise patients to stop smoking, lose weight, control their diabetes, and “get a bit fitter” before major surgery. That advice was well-intentioned but unstructured. It was rarely backed by a written plan, rarely involved any specialist input beyond the surgeon, rarely had measurable goals, and rarely had any follow-up to check whether anything had actually been done.

Structured prehab is fundamentally different. It involves explicit assessment of all six pillars at the start of the prep window, a written plan for each pillar, often the involvement of physiotherapists, dietitians, psychologists, smoking cessation specialists, and pharmacists, regular check-ins to track progress, and a re-assessment shortly before the operation to confirm the patient is as ready as they can be.

So while the underlying idea – “be in better shape before surgery” – is old, the delivery is new. And it is the structured delivery, not the underlying idea, that produces the measurable improvements in outcomes.

What the evidence actually shows

The honest version of the evidence base is as follows.

Across multiple randomised trials and meta-analyses, structured prehab before major abdominal, cardiac, thoracic, and orthopaedic surgery has been shown to reduce the rate of post-operative complications – particularly pulmonary complications such as pneumonia, and surgical complications such as wound infections – and to shorten the average length of hospital stay by one to several days. Patients return to normal activities faster and report better quality of life in the months after surgery.

Evidence for a mortality benefit is more modest – partly because mortality after most elective surgery is already low, so detecting a further reduction requires very large studies. Where the surgery is genuinely high-risk (major liver, pancreatic, oesophageal, or extensive cardiac surgery), the signal for mortality benefit is stronger.

Evidence is still developing in certain groups – very elderly patients, patients having neoadjuvant chemotherapy before surgery, and patients undergoing palliative-intent operations. The general direction of evidence is favourable, but recommendations in those settings should be tailored to the individual.

What evidence does NOT show is that prehab is a substitute for surgery, that it makes cancer smaller, or that it removes the inherent risk of major operations. It modifies the risk – meaningfully, but not magically. Understanding this honestly is part of what makes prehab work.

Who benefits most from prehab – including the counterintuitive answer

Almost any patient facing major elective surgery benefits in some way from a structured prep window. But some groups benefit disproportionately.

• Patients with low baseline physical fitness. The intuitive assumption is that fit patients gain the most. The evidence is the opposite – the less fit a patient is at baseline, the larger the absolute improvement they make from prehab, and the larger the impact on their surgical outcomes. If you’re worried that you’re “too unfit” to benefit, the opposite is true.

• Patients with malnutrition or sarcopenia (loss of muscle mass). Often invisible – people with normal body weight can still be sarcopenic – but a strong predictor of post-operative complications, and a strong responder to nutritional and physical prehab.

• Patients with poorly-controlled chronic conditions. Diabetes with high HbA1c, uncontrolled blood pressure, anaemia, untreated obstructive sleep apnoea, poorly-controlled COPD – all materially improvable in a 4 to 6 week window if addressed deliberately.

• Smokers. The single highest-impact intervention available in surgical preparation is smoking cessation. Even four weeks of cessation before surgery measurably improves wound healing and reduces chest complications.

• Patients with significant anxiety, depression, or sleep disturbance. Often the most underemphasised pillar in practice; often the highest-impact for the individual patient.

• Older patients (broadly, over 70). Older patients tolerate insults less well; prehab increases the reserve they bring to the operation.

• Patients who live alone or have limited home support. The practical pillar of prehab – preparing the home environment, arranging support, organising transport – has outsized impact for this group.

If you’re in one or more of these groups, prehab matters more for you. If you’re in none of them, it still matters – just by a smaller margin.

The six pillars of prehab

Modern prehab is multimodal. The framework most commonly taught involves six pillars, each with its own evidence base and its own practical actions. The pillars overlap – improving nutrition supports physical conditioning, which supports psychological well-being – but they are useful to consider separately because each requires its own deliberate attention.

Pillar 1 – Physical conditioning

The aim is not to become an athlete. The aim is to arrive at the operating theatre with greater cardiorespiratory reserve and muscle strength than you have today. The structure that works well includes:

• Aerobic exercise – walking, cycling, or swimming at a moderate intensity (the level where you can hold a conversation but feel the effort), 30 to 45 minutes most days of the week, ideally with some gradient or interval variation.

• Strength work – resistance exercises two or three times a week. Sit-to-stand from a chair, wall press-ups, simple resistance band work for arms and legs. No gym required.

• Flexibility and balance – gentle stretching, yoga, or tai chi as tolerated. Often neglected but matters for post-operative recovery, especially in older patients.

If you currently do nothing, start small – a 15-minute walk daily and three repetitions of sit-to-stand morning and evening. Build from there. The improvement curve in the first two weeks is steep – your body responds quickly even to modest stimulus when it has been deconditioned. If you have mobility limitations, your physiotherapy team or local professional can adapt all of this – there is a version of physical prehab for almost every starting point.

Pillar 2 – Nutritional optimisation

Surgery is a metabolic stress. Patients who arrive nutritionally depleted recover less well and are more vulnerable to complications. The aim of nutritional prehab is to arrive at theatre with adequate protein reserves, stable body weight, and corrected micronutrient deficiencies.

Practically:

• Protein intake – aim for around 1.2 to 1.5 grams per kilogram of body weight per day (higher than the general adult recommendation). For a 70 kg / 154 lb person that is roughly 85 to 105 grams of protein daily – meat, fish, eggs, dairy, legumes, and tofu are the main sources. Spread it across three meals; protein at breakfast matters more than people think.

• Energy intake – avoid unintended weight loss in the prep window. If you have been losing weight, this is the window to reverse it if possible. Oral nutritional supplement drinks (commonly available brands include Ensure, Fortisip, Boost) are appropriate if you can’t get there with food alone.

• Micronutrient correction – iron deficiency anaemia is common and significantly worsens surgical outcomes; vitamin D, vitamin B12, and folate are worth checking. Your team or GP can request blood tests and correct deficiencies in the prep window.

• Hydration – adequate daily fluid intake matters. Aim for clear urine most of the day.

• Alcohol – minimise. Heavy drinkers should stop or substantially reduce intake in the weeks before surgery; the body needs the liver function for the operation and recovery.

Working with a dietitian – if one is available through your team or privately – pays off in this pillar more than almost any other.

Pillar 3 – Psychological preparation

The most underemphasised pillar in practice. Surgery is psychologically demanding for almost everyone – fear, anxiety about outcomes, anticipated grief, anxiety about family, sleep disturbance, low mood. Patients who arrive psychologically prepared tolerate the operation and the recovery period better, engage more effectively with their rehab, and report better quality of life months and years later.

What helps:

• Information and understanding – knowing what is going to happen, in detail, reduces anxiety for most people. This site, your surgical team, and reliable patient organisations are sources to lean on.

• Mental rehearsal – visualising the day of surgery, the immediate aftermath, the early recovery period. Not avoidance – engagement.

• Mindfulness, meditation, or relaxation practices – there is good evidence that brief daily practice reduces pre-operative anxiety and improves sleep. Many free apps and guided audio recordings are available.

• Treatment of pre-existing anxiety or depression – if you are already struggling with either, the weeks before surgery are not the time to manage alone. Speak to your GP or mental health provider. Adjustment of existing medications, brief psychological therapy, or simply a structured conversation with a professional can make a meaningful difference.

• Sleep – protect it. Reduce alcohol, caffeine in the afternoon, screens before bed. If your sleep is significantly disrupted, talk to your team – short-term sleep support may be appropriate.

• Connection – isolation worsens anxiety. Talk to family, to friends, to other patients who have been through similar surgery. Patient support organisations relevant to your condition can connect you with people who understand the territory.

If you find yourself unable to think about the operation, dreading the prep, or unable to sleep, those are signals worth flagging to your team – not signs of weakness, but signs that this pillar needs more attention.

Pillar 4 – Medical optimisation

This pillar covers the active management of pre-existing medical conditions in the weeks before surgery. The aim is to arrive at theatre with chronic conditions as well-controlled as possible, so that the surgery is built on a stable physiological base.

Common areas:

• Diabetes – blood sugar control matters greatly. If your HbA1c is high, your team may want to tighten control in the weeks before surgery. Diabetic patients also often need adjusted medication regimens around the operation; this conversation should happen well in advance, not the day before.

• Blood pressure – uncontrolled hypertension increases peri-operative risk. If your blood pressure has been running high, get it reviewed and adjusted now.

• Anaemia – common and underdiagnosed. Iron deficiency anaemia is reversible in 4 to 6 weeks with appropriate iron treatment (oral or intravenous). Arriving at surgery anaemic increases your risk of needing transfusion and worsens recovery.

• Respiratory conditions – COPD, asthma, sleep apnoea. Optimised inhaler regimens, treatment of any active infection, and CPAP for diagnosed sleep apnoea all matter.

• Cardiac conditions – if you have a known heart condition, your cardiologist may need to be involved in the pre-operative planning. Don’t assume your surgical team will loop them in automatically — sometimes you need to prompt this.

• Medication review – every medication you take should be reviewed before surgery. Some may need to be stopped, some adjusted, some swapped. This is particularly important for blood-thinners, diabetes medications, blood pressure medications, immunosuppressants, and herbal supplements.

Your primary care doctor – your GP, family doctor, or primary care physician – has a central role in this pillar. Many of these optimisations are done at the primary care level, not at the surgical hospital. Ask for a pre-operative review appointment specifically – not just a general check-up.

Pillar 5 – Smoking, alcohol and substance use

This pillar gets its own focus because the gains from change here are unusually large, rapid, and immediate.

Smoking – the single highest-impact intervention available in surgical preparation. Stopping smoking for at least four weeks before surgery measurably reduces wound infections, wound healing problems, chest infections, and the risk of needing prolonged ventilation. Eight weeks is even better. The benefit begins within days of stopping. Nicotine replacement therapy, varenicline, or other smoking cessation aids are entirely appropriate – talk to your primary care physician. Vaping is not a clean substitute and is best stopped too where possible.

Alcohol – heavy drinkers (more than around 14 units per week, with the threshold different by sex and country guidelines) face elevated risk of post-operative complications, particularly bleeding, infection, and delirium. Reducing or stopping alcohol intake in the four weeks before surgery measurably reduces these risks. If you are dependent on alcohol, do not stop abruptly without medical supervision – speak to your GP.

Recreational drugs – cocaine, opioids, cannabis, stimulants, and others all interact with anaesthesia and the perioperative period. Honest disclosure to your anaesthetic team – in confidence – is important for your safety. They are not there to judge; they need to know to keep you safe under anaesthesia.

Cannabis specifically – increasingly common globally; affects anaesthetic dose requirements and post-operative pain control. Stopping for two weeks before surgery is recommended where possible, and disclosure to the anaesthetic team is essential.

Pillar 6 – Social and practical preparation

The least medically-flavoured pillar, but often the one that determines how well the first few weeks after discharge actually go. The aim is to arrange your life so that the recovery period is supported, predictable, and free of avoidable stress.

Areas to plan:

• Home environment – move things you use daily to waist-height to minimise bending and stretching while wounds heal. Prepare a comfortable rest area on the ground floor if you live in a multi-storey home. Clear walking paths of trip hazards.

• Support network – identify who will help with shopping, cooking, cleaning, childcare, and transport during the first 2 to 4 weeks at home. Most people underestimate the support they will need. Ask early; people generally want to help but appreciate specific asks rather than vague offers.

• Transport – plan how you will get home from hospital, and how you will get to follow-up appointments. Driving is restricted after most major operations for several weeks.

• Work and income – speak to your employer early about expected time off. Sick leave arrangements vary by country and employer; clarify what you are entitled to. If you are self-employed or in informal work, the financial planning is more complex; do it in advance.

• Insurance and financial – understand what your health insurance covers, what your out-of-pocket exposure will be, and how to navigate the financial side. This varies enormously by country, so the specifics differ – but the planning step is universal.

• Childcare and dependant care – if you care for children, elderly parents, or other dependants, plan their care for the period when you will be unable to do so.

• Advance care planning – for major surgery in particular, it is worth completing or updating an advance directive (also called a living will or healthcare proxy), even if you have no expectation of needing it. This is a kindness to your family and a way of taking ownership of your own care.

• Practical at-home preparation – have comfortable loose clothing ready, a supply of easy-to-prepare nutritious meals frozen and labelled, contact details for your team in an accessible place, a notebook for questions and observations.

This pillar is also where the role of family and caregivers becomes central – see our separate article for families.

What prehab isn’t – common myths worth busting

• Prehab is not a substitute for surgery. It modifies your risk and improves your recovery; it does not remove the need for the operation.

• Prehab is not just for the very fit. The less fit you are at baseline, the more you stand to gain. If your starting point is low, your gains are large.

• Prehab is not too late if you only have 2 or 3 weeks. Short-window prehab still produces measurable improvement, especially in nutrition, smoking cessation, and medical optimisation.

• Prehab is not solely the patient’s responsibility. It is a system-of-care concept that should involve your surgical team, anaesthetic team, GP, physiotherapist, dietitian, and others. If your team isn’t offering structured support, that’s a feature of where we still are in healthcare – not a sign that prehab doesn’t matter.

• Prehab is not only physical. The four pillars beyond physical conditioning – nutrition, psychology, medical optimisation, lifestyle, and practical preparation – are all evidence-based and all matter.

• Prehab is not expensive. Most of what matters is free – walking, eating well, sleeping, talking honestly with your team, stopping smoking, organising your home. Specialist input is helpful where available but not strictly required.

• Prehab is not optional in the sense that it can safely be ignored. The evidence is strong enough that the question is no longer “does it work” but “how do we deliver it well”.

The time window – what if you only have 2 weeks? 4 weeks? 8 weeks?

Different prep windows allow different things. The honest framing:

If you have 8 weeks or more

All six pillars in full. Substantial gains possible in cardiorespiratory fitness, muscle strength, nutritional state, smoking cessation, control of chronic conditions, psychological preparation, and practical organisation. The most common surgical preparation window globally.

If you have 4 to 6 weeks

Still substantial. Prioritise nutrition, smoking cessation, medical optimisation, psychological work, and practical preparation; physical gains are real but smaller in this window. Most patients reading this article will be in this category.

If you have 2 to 3 weeks

Focus on the highest-yield items: smoking cessation (gains begin within days), nutrition (protein loading, oral supplements if needed), medical optimisation (particularly anaemia and diabetes), psychological preparation, and practical preparation. Skip ambitious physical conditioning targets; instead, build in daily walks and a few sit-to-stand sets to maintain function.

If you have 1 week or less

Concentrate on what is still reversible in days: nutrition (eat well, hydrate, protein), alcohol cessation, optimising chronic-condition medications, sleep, psychological preparation, and the practical organisation of your home and support network. Even at this window, the work is worthwhile.

If you are facing emergency surgery

Most of structured prehab does not apply in true emergencies. But even there, the principles of involving family, organising support for after, and arriving with clear information about your medications and conditions all matter. Some of the recovery-side work (rehab) carries the same logic – and is even more important when prehab was not possible.

Working with your team – questions to ask, things to request

Healthcare systems vary enormously in how proactively they offer prehab. Some have structured prehab pathways with dedicated teams; many do not. Wherever you are, the following questions are reasonable to ask, and the following requests are reasonable to make.

Questions for your surgeon or surgical nurse

• Is there a formal prehab service at this hospital that I can be referred into?

• Are there specific things you would like me to do or avoid in the weeks before surgery?

• Are there blood tests or assessments you would like done in the next few weeks?

• Are there medications or supplements I should stop, and when?

• Who should I contact if I have questions or concerns in the prep window?

Questions for the anaesthetic pre-assessment

• Based on my fitness and conditions, what are the specific risks I should know about?

• Is there anything I could change in the next few weeks that would meaningfully reduce those risks?

• Are there particular medications or substances I should disclose now?

• What’s your view on smoking cessation, alcohol reduction, or other lifestyle changes in my case?

Questions for your GP / family doctor / primary care physician

• Can we do a pre-operative medical review specifically – not just a general check?

• Are any of my chronic conditions worth optimising more aggressively in the run-up?

• Can we check my iron, vitamin D, B12, and HbA1c if appropriate?

• Do I need any vaccinations or other preventive care before surgery?

Things to request, where available

• Referral to a physiotherapist for a personalised pre-operative exercise plan

• Referral to a dietitian for nutritional assessment and advice

• Smoking cessation support (counselling, nicotine replacement, prescribed medication)

• Anxiety / mood support if you are struggling

• Pre-operative anaemia clinic referral if anaemic

• Sleep assessment if you snore heavily, are excessively sleepy in the day, or your partner has noticed breathing pauses at night

The role of family and caregivers

Caring for someone recovering from major surgery is harder than most people expect. Lifting, supporting, managing medications, attending appointments, providing emotional support, holding everything else together – it adds up. Patients who arrive at theatre with a clear plan for caregiver support recover better, and the caregivers themselves fare better.

The basic ask of family and caregivers in the prep window is: be informed, be planned, and prep yourselves. There is a separate article for family and caregivers in this foundational series – read it together with the patient if you can.

‘For family members and caregivers, see our dedicated companion article.

A first-week starter checklist

If you are reading this newly aware of your upcoming surgery and don’t know where to start, the following short list will get you moving in the right direction within the first seven days:

• Book a pre-operative medical review with your primary care doctor. Specifically ask for a pre-op review, not a general check-up.

• Start daily walking – 15 to 30 minutes at moderate pace. Build up over the next two weeks.

• If you smoke, stop today. Ask for support.

• If you drink alcohol regularly, reduce now; aim to stop in the final two weeks.

• Increase protein intake at every meal. Add an oral nutritional supplement if you have been losing weight.

• List every medication and supplement you take. Bring the list to your pre-operative review.

• Identify two or three people who will support you in the first 2-4 weeks after surgery. Speak to them now.

• Write down every question you have. Bring the list to your next appointment.

• Find one daily 10-minute practice that calms you – walking outdoors, meditation, breathing exercises, a phone call with a friend. Build it into your day.

• Identify a patient organisation relevant to your condition and read one of their patient information resources this week.

Find your situation – navigation hub

This article is the foundation. The disease-specific articles on this site go deeper into what prehab looks like for your particular surgery. If you’ve been told you need:

• Surgery for liver disease – see our Liver Surgery cluster (overview, colorectal liver metastases, hepatocellular carcinoma, cholangiocarcinoma, neuroendocrine tumour liver metastases)

• Surgery for pancreatic disease – see our Pancreatic Surgery cluster (Whipple procedure, distal pancreatectomy, total pancreatectomy)

• Surgery affecting digestion – see our practical guides (pancreatic enzyme replacement, Type 3c diabetes, splenectomy and vaccinations)

More articles are added regularly. If your particular surgery is not yet covered, the six-pillar framework in this article applies. Bring the printable starter checklist with you to your pre-operative appointments and let your team adapt it to your situation.

A note on different healthcare systems

Prehab matters everywhere, but how easy it is to access varies enormously by country and by individual healthcare system. Some readers will be in systems with established prehab pathways and dedicated teams; many will be in systems where prehab is patient-driven and supported by their own initiative, family, and primary care doctor.

The principles in this article are deliberately written to be applicable wherever you are. The conversations to have, the actions to take, the resources to seek – all of these translate across systems. Specific details – medication names, professional titles, referral pathways, insurance considerations – will differ in your local context. Your primary care doctor and your surgical team are the right guides for those specifics.

Closing – the most important thing to take away

If you remember one thing from this article: the weeks before surgery are not waiting time. They are working time. The work is not glamorous and the gains compound quietly. But that quiet, compounding work – across the six pillars, done deliberately over the weeks you have – is genuinely transformative for how surgery goes and how recovery unfolds.

Start today. Start small if you need to. Build from there. The body and mind respond faster than people expect when they begin.

And ask for help – from your team, from your family, from your primary care doctor, from this site, and from the wider patient community. Prehab is not a solo effort, and nobody is expected to figure it out alone.

This article was written and reviewed by Mr Tom Gallagher, Consultant Hepatobiliary and Pancreatic Surgeon. It is for general patient information and is not a substitute for advice from your own clinical team.

Last updated: 7 June 2026.