Our operating criteria
When we don't operate — and how we decide
Not every piles, fistula, fissure, hernia or varicose-vein patient needs an operation. At Sharvari Hospital the decision follows written criteria — grade, symptoms, examination and, for fistula, imaging — not a sales target. Below is the same checklist Dr Kundan Kharde (MBBS · MS (General Surgery), 19+ years, 6,000+ Surgeries) uses in the OPD, with what we offer instead when surgery is not the answer.
Each table below is built from a published surgical guideline. It is a guide to how we think, not a diagnosis: which row applies to you is decided after examination, and imaging where stated. Results vary.
How is the decision to operate made at Sharvari Hospital?
Sharvari Hospital is surgeon-owned and surgeon-run. There is no sales team, no monthly surgery target, and no one paid to convert your consultation into an operation. If you don't need surgery, we will tell you — and we've written that into our own case studies.
- ✓Examination first. The grade, type or stage of your condition is decided on examination, not from symptoms or a report alone.
- ✓Imaging where it changes the decision. Almost every fistula is imaged before we decide — the operation follows the scan, not the calendar.
- ✓Second opinions are welcome, including on surgery done elsewhere.
- ✓A written plan either way. You leave with an OPD summary of the findings and the plan, whether or not it includes surgery.
When do piles not need surgery?
Most Grade 1 and Grade 2 piles do not. They are treated with diet, medicines and, if bleeding persists, an office procedure — rubber band ligation, sclerotherapy injection or infrared coagulation — without an operation. Grade 3 and Grade 4 piles usually need day-care surgery. The grade is assigned on examination (proctoscopy), not from symptoms alone. Results vary.
| Finding | Our usual plan | Why |
|---|---|---|
| Grade 1 — bleeding, no prolapse | Fibre, fluids, stool softener, medicines; review in a few weeks | Dietary fibre is first-line treatment for symptomatic piles (ASCRS 2018). |
| Grade 2 — prolapse that goes back on its own | Diet and medicines; office procedure (banding, sclerotherapy or IRC) if bleeding continues | Office procedures are recommended for Grade 1–2 piles that fail medical treatment (ASCRS 2018). |
| Grade 3 — prolapse you push back by hand | Usually day-care surgery; banding may still be tried for selected smaller piles | Surgery is recommended when office treatment fails or is unsuitable (ASCRS 2018). |
| Grade 4 — prolapse that stays outside, or a large external component | Day-care surgery | Excisional or stapled surgery is the guideline option for advanced or mixed piles (ASCRS 2018). |
Full grade-by-grade options: piles treatment without surgery · pillar: piles treatment in Pune.
Source: Davis BR et al. ASCRS Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2018. Decided after examination; results vary.
Does a fistula ever heal without surgery?
Honestly, an established anal fistula rarely closes on its own, so most do need an operation in the end. What we do not do is operate before the tract is mapped: almost every fistula is imaged before we decide. An acute abscess is drained first, and a fistula linked to Crohn's disease is brought under medical control before any definitive surgery. Results vary.
| Finding | Our usual plan | Why |
|---|---|---|
| Acute abscess, no defined tract yet | Drainage first; whether a definitive fistula operation is needed is decided later | Prompt drainage is the treatment of an anorectal abscess; not every abscess leaves a fistula (ASCRS 2022). |
| Defined fistula tract | MRI fistulogram or trans-rectal ultrasound before any operation — almost every fistula is imaged | Imaging shows depth, branches and how much sphincter the tract crosses, which decides the safe operation (ASCRS 2022). |
| Crohn's-related (IBD-associated) fistula | Medical control first with a gastroenterologist; surgery only to drain sepsis or after the disease is controlled | Crohn's perianal fistulas are managed jointly, medical therapy first, with drainage/seton for sepsis (ASCRS). |
How the operation is chosen: how Dr. Kharde decides · can a fistula be treated without surgery? · fistula with Crohn's or TB.
Source: Gaertner WB et al. ASCRS Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula. Dis Colon Rectum. 2022. Decided after examination; results vary.
When does a fissure not need surgery?
Most acute fissures — under about eight weeks old — heal without an operation, with fibre, fluids, warm sitz baths, a stool softener and a prescribed ointment. A chronic fissure is still treated with medicine first. Botox or lateral internal sphincterotomy is considered only when a chronic fissure has not healed on medical treatment. The type of fissure is decided on examination. Results vary.
| Finding | Our usual plan | Why |
|---|---|---|
| Acute fissure (under ~8 weeks) | Fibre, fluids, sitz baths, stool softener, topical ointment | Non-operative care is first-line and heals many acute fissures (ASCRS 2023). |
| Chronic fissure, not yet treated with ointments | A course of topical GTN or diltiazem, with the measures above | Topical nitrates or calcium-channel blockers are first-line for chronic fissure (ASCRS 2023). |
| Chronic fissure that has not healed on medical treatment | Botox injection or lateral internal sphincterotomy (LIS), chosen with you | Botulinum toxin or LIS is recommended after medical therapy fails (ASCRS 2023). |
| Atypical fissure (off the midline, multiple, or without the usual pain) | Further tests before any operation | Atypical fissures need evaluation for an underlying cause (ASCRS 2023). |
Pillar: fissure treatment in Pune · Hindi: fissure में क्या खाना चाहिए.
Source: Stewart DB et al. ASCRS Clinical Practice Guidelines for the Management of Anal Fissures. Dis Colon Rectum. 2023. Decided after examination; results vary.
When is a hernia watched instead of repaired?
A hernia does not close on its own, but not every hernia needs repair straight away. In men with a small inguinal hernia that causes no or minimal symptoms, watchful waiting with regular review is a guideline-accepted option. We advise repair when the hernia is painful, limits activity or is getting bigger — and for any femoral hernia. Decided after examination. Results vary.
| Finding | Our usual plan | Why |
|---|---|---|
| Man with an inguinal hernia causing no or minimal symptoms | Watchful waiting with review; what to watch for explained in writing | Watchful waiting is acceptable for these patients (HerniaSurge 2018). |
| Painful, limiting activity, or enlarging hernia | Planned repair | Symptomatic inguinal hernias are repaired (HerniaSurge 2018). |
| Femoral hernia, or a groin hernia in a woman | Prompt planned repair — not watched | Higher strangulation risk; femoral hernias are repaired (HerniaSurge 2018). |
| Tense, painful lump that will not go back | Emergency assessment and surgery | Possible incarceration or strangulation (HerniaSurge 2018). |
Pillar: hernia surgery in Pune · hernia symptoms — when is surgery necessary?.
Source: HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018. Decided after examination; results vary.
When do varicose veins not need EVLT?
Spider veins and small reticular veins without symptoms (CEAP C1) do not need EVLT; they are a cosmetic concern, not a medical one. EVLT is considered for symptomatic veins — aching, heaviness, swelling, itching — when a duplex ultrasound confirms reflux in a main (truncal) vein, or when there are skin changes, bleeding or an ulcer. Decided after examination and duplex scan. Results vary.
| Finding | Our usual plan | Why |
|---|---|---|
| Spider or reticular veins (C1), no symptoms | No EVLT; reassurance, walking, leg elevation; sclerotherapy only if you want it for appearance | Cosmetic veins are not an indication for ablation (NICE CG168). |
| Visible varicose veins, no symptoms, no skin changes | No procedure needed; advice and review if symptoms start | Referral for treatment is for symptoms or complications (NICE CG168). |
| Symptomatic veins with truncal reflux on duplex ultrasound | EVLT (endothermal ablation) considered | Endothermal ablation is first-line for confirmed truncal reflux (NICE CG168). |
| Skin changes, ulcer, superficial vein thrombosis or bleeding vein | Treatment prioritised after duplex | These are referral indications (NICE CG168). |
EVLT at Sharvari is performed by Dr. Kundan Kharde, with Dr. Shrikant Ghanwat (vascular surgeon) as in-house backup. Compression stockings are offered when a procedure is unsuitable. Pillar: varicose veins treatment.
Source: NICE CG168. Varicose veins: diagnosis and management. 2013. Decided after examination; results vary.
Are silent gallstones operated on?
Usually not. Silent gallbladder stones are not always operated on; we tell you when the answer is “not yet” or “not at all”. Stones found by chance on a scan, with no symptoms and a normal gallbladder and bile duct, generally need no treatment. Surgery is offered for biliary colic, cholecystitis, gallstone pancreatitis or stones in the bile duct. Decided after examination and ultrasound. Results vary.
| Finding | Our usual plan | Why |
|---|---|---|
| Stones found incidentally, no symptoms, normal gallbladder and bile duct | No operation; you are told which symptoms mean you should come back | Reassure — no treatment unless symptoms develop (NICE CG188). |
| Biliary colic (typical upper-abdominal pain) | Laparoscopic cholecystectomy offered | Recommended for symptomatic gallbladder stones (NICE CG188). |
| Acute cholecystitis | Laparoscopic cholecystectomy, ideally within a week of diagnosis | Early surgery recommended (NICE CG188). |
| Gallstone pancreatitis or stones in the bile duct | Bile-duct clearance and cholecystectomy | Recommended even for bile-duct stones without symptoms (NICE CG188). |
Pillar: gallbladder stone surgery.
Source: NICE CG188. Gallstone disease: diagnosis and management. 2014. Decided after examination; results vary.
When does a pilonidal sinus not need surgery?
When it causes no trouble. A small pit at the top of the buttock cleft with no pain, discharge or abscess does not need an operation — hygiene, hair control and observation are enough. An acute abscess is drained first. Planned surgery, laser or excision, is advised for a recurrent abscess or persistent discharge. Decided after examination. Results vary.
| Finding | Our usual plan | Why |
|---|---|---|
| Pit(s) only — no pain, discharge or abscess | No operation; hygiene, hair removal, review if symptoms start | Asymptomatic pilonidal disease is not treated surgically (ASCRS 2019). |
| Acute pilonidal abscess | Drainage first; definitive surgery decided once it settles | Incision and drainage for acute abscess (ASCRS 2019). |
| Recurrent abscess or persistent discharge | Planned laser or excision surgery | Chronic symptomatic disease is treated surgically (ASCRS 2019). |
Pillar: pilonidal sinus treatment.
Source: Johnson EK et al. ASCRS Clinical Practice Guidelines for the Management of Pilonidal Disease. Dis Colon Rectum. 2019. Decided after examination; results vary.
What do you get instead of surgery?
A plan you can follow at home and a date to come back. When an operation is not advised, you leave with the same written OPD summary a surgical patient gets — findings, diagnosis and plan — plus:
- ✓Medicines with the dose and how long to take them.
- ✓A diet sheet — see diet for piles, fissure and fistula, or in Hindi: fissure में क्या खाना चाहिए, fissure बिना ऑपरेशन, भगंदर बिना ऑपरेशन.
- ✓A review date, so the plan is checked rather than left open.
- ✓A “come back sooner if…” list — heavier bleeding, a lump that no longer goes back, fever, severe pain or a painful, hard hernia.
Second-opinion patients are welcome to bring outside reports and MRI scans.
Cases where we said no
We document these decisions in our case notes; anonymised examples are being added. Our published case studies show the same approach from the other side — where examination and imaging changed which operation was done.
Frequently asked questions
Will I be pushed into surgery if I come for a consultation? +
No. Sharvari Hospital is surgeon-owned and surgeon-run, with no sales team and no monthly surgery target. Dr. Kharde examines you, orders imaging only where the criteria on this page call for it, and gives you a written plan. Many first visits end with diet, medicines and a review date. If you do not need surgery, we will tell you.
Can I get a second opinion on whether I need an operation? +
Yes. Second opinions are welcome, including when surgery has been advised or done elsewhere. Bring your outside reports, scans and MRI. Dr. Kharde examines you, compares the findings with the criteria on this page and tells you plainly whether he agrees an operation is needed now, later or not at all.
Do you charge differently if surgery is not advised? +
A consultation is a consultation. There is no incentive tied to surgery, and the decision to operate is made on the examination and imaging findings, not on the bill. If a procedure is advised, its cost is explained before anything is booked.
How do I know the non-surgical plan is working? +
Your written plan includes a review date and a "come back sooner if…" list — for example, heavier bleeding, a lump that no longer goes back, fever or severe pain. At review, Dr. Kharde checks your symptoms and examines you again. If the plan is not working, the options, including surgery, are discussed then. Results vary.
Do you image every fistula before surgery? +
Almost every fistula is imaged before we decide — an MRI fistulogram or a trans-rectal ultrasound. Imaging shows how deep the tract runs, whether it has branches and how much sphincter muscle it crosses. Those findings decide which operation is safe, so the operation follows the scan.
Who makes the final decision — the surgeon or me? +
You do. Dr. Kharde tells you what he finds, what the guideline-based options are — including watching and waiting where that is safe — and what he recommends and why. The decision to have, delay or decline an operation is yours, and you are welcome to take the written plan home and think it over.
Not sure you need an operation? Ask first.
Dr. Kharde examines you and tells you whether an operation is needed now, later or not at all.
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