Bleeding in the immediate postoperative period is a rare event that must be suspected in the presence of acute hypotension,tachycardia, contraction of the urinary output, or shock. The absence of intraabdominal drainage may cause a delay in diagnosis and necessitate an urgent, rather than semielective, reoperation. Bleeding may come from an intraoperative vascular repair, any splenic or hepatic injury that rebleeds after hemostasis has apparently been achieved, or from the incision itself, possibly involving an intercostal artery or vein after thoracotomy or the epigastric artery caused by trocar placement for laparoscopy. Watson and colleagues51 reported on a patient who underwent a laparotomy 6 hours after the initial laparoscopic anti-reflux operation for bleeding caused by slippage of a clip placed on a short


gastric vessel. To prevent such a complication, it is wise to apply two hemostatic clips on both sides of the presumed division point of a vessel. This is especially important because such clips can be dislodged while passing the fundus through the retroesophageal window to wrap the lower esophagus.

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