Intermuscular Fibrolipoma of the Neck: A Rare Case Report

Lipomas are slow growing tumors rarely found in children. We report a very rare case of an intermuscular fibrolipoma found deep within the posterior triangle of the neck. A 3 year old child was brought with the complaints of right sided neck mass and an inability to fully turn his head for two months. Ultrasound and computed tomography of the neck suggested a diagnosis of intermuscular lipoma. The patient was successfully managed by complete surgical resection of the mass. Histopathological examination confirmed the diagnosis as intermuscular fibrolipoma. Due to the rarity of the case, we are prompted to report it.

Thyroglossal Duct Remnants: A Comparison in the Presentation and Management Between Children and Adults

Seventy one patients (43 children and 28 adults) of thyroglossal duct remnants (TGDRs) presented at a tertiary care institute from January 2001 to September 2017 were retrospectively analysed. The mean age of presentation was 7.15 years in children and 26.85 years in adults. The male to female ratio was 1.9:1 among children and 1.8:1 among adults. The most common presentation in children was a thyroglossal fistula (53.48%) whereas it was a painless cystic neck swelling (89.29%) in adults. All the children underwent a Sistrunk's operation whereas 78.57% of the adult patients underwent simple excision of cyst/fistula using the modified incision (Yadav's incision). Recurrence developed in one child and one adult patient who underwent Sistrunk's operation and none in the modified incision, these cases were treated with a second stage procedure. In conclusion, compared with adults, more children presented with a discharging thyroglossal fistula. The thyroglossal duct remnants can be managed successfully by simple excision in adults.

Clinical profile and outcome of neonates with congenital diaphragmatic hernia: A 16-year experience from a developing country

Recent advances in the perinatal interventions for neonates with congenital diaphragmatic hernia have remarkably improved the outcome in developed countries, but high mortality for such cases continues to be a challenge in resource-poor settings. This study examines clinical profiles and short-term outcome of neonates with congenital diaphragmatic hernia, using a retrospective analysis of medical records of neonates operated for congenital diaphragmatic hernia at a tertiary care center in North India from January 2001 to December 2016. Forty-two neonates were operated during the study period with male:female ratio = 1.6:1. Postoperative survival rate was 69% (29/42). Average birth weight in the survivors was 2528±267 g as compared with 2132±309 g in the non-survivors. The average gestational age in the two groups was 37.2±0.8 weeks and 34.8±1.8 weeks respectively. Twenty-one patients presented in the initial 48 h of life, out of them 52% (11/21) survived. Congenital heart diseases were associated with seven and malrotation of the gut in five neonates. The most significant factors resulting in the unfavorable outcome were preterm gestation, low birth weight, hypothermia and shock at presentation, the onset of symptoms <48 h of life, liver-up, need of postoperative inotropes and mechanical ventilation. In addition to establishing advanced therapeutic modalities, good antenatal screening, better awareness in peripheral health workers about the malformation leading to timely referral, well-equipped inter-hospital and intra-hospital transport facilities and development of level III neonatal intensive care units can improve survival in neonates with congenital diaphragmatic hernia in developing countries.

Diagnostic challenges in late-presenting congenital diaphragmatic hernia: a 16-year experience from tertiary care centre in North India

With increasing use of ultrasound screening, the prenatal diagnosis of congenital diaphragmatic hernia (CDH) in better resourced areas has become the norm. However, early diagnosis is still not universal in resource-poor settings and late presentations of CDH continue. We retrospectively analysed the medical records of children operated for late-presenting CDH from 2001 to 2016 at our tertiary care centre in North India. A total of 32 patients were operated during the period with a male-to-female ratio of 3:1. Of these, 78% presented with respiratory symptoms, 37% with recurrent vomiting and 18% with an acute abdomen. Nine (28%) had been treated erroneously for gastroenteritis and another six (18%) had received anti-tubercular therapy for variable periods. A plain chest radiograph with a Ryle's tube in situ was confirmatory in 75% (24/32). In conclusion, initial misdiagnosis and subsequent unnecessary therapeutic interventions were the leading cause of morbidity .

Intramural Duodenal Hematoma In 2-year Old Child

Background: Intramural hematoma of the duodenum is a rare cause of acquired duodenal obstruction. It is often a diagnostic dilemma and a high degree of suspicion is required to make an early and accurate diagnosis in children. Case Report: A 2-year-old child presented with bilious vomiting and abdominal distension. X-ray abdomen showed high intestinal obstruction. Ultrasound and CT scan abdomen gave suspicion of pancreatic pseudo-cyst near head of pancreas. At surgery, an intramural hematoma of the duodenum was found and drained. Conclusion: Intramural duodenal hematoma is a rare entity especially in children and should be considered in differential diagnosis of acquired duodenal obstruction.

Gastric Perforation Due to Blunt Trauma Abdomen

Blunt trauma abdomen rarely leads to gastrointestinal injury in children and isolated gastric rupture is even rarer presentation. We are reporting a case of isolated gastric rupture after fall from height in a three year old male child.

Congenital pulmonary airway malformation mimicking as pulmonary tuberculosis in five paediatric patients: a diagnostic dilemma

A series of five children with delayed presentation of congenital pulmonary airway malformation (CPAM), all initially misdiagnosed as pulmonary tuberculosis, is described. All five children presented with recurrent respiratory infections and failure to thrive, having shown poor response to multiple antibiotics course, including anti-tubercular therapy for variable periods. Successful surgical intervention was belatedly instigated.

Right Inguinal Obstructed Littre's Hernia in a Child

Littre’s hernia, in which the hernia sac contains a Meckel’s diverticulum, is extremely uncommon in paediatric population. We are reporting a case of Littre hernia in a 4.5 year old male child who presented with an irreducible mass in right inguinal region. The diagnosis was made peroperatively. The patient was successfully managed by diverticulectomy and herniotomy and is doing well in follow up.J Nepal Paediatr Soc 2016;36(3):300-302

Anorectal Malformations: Histomorphological and Immunohistochemical Evaluation of Neuronal Dysfunction

Objective :

The patients with anorectal malformations (ARM) have been identified with specific and non-specific pathological changes. The present study was conducted with the aim to study histomorphological changes and various immunohistochemical (IHC) markers (calretinin, S-100, CD117) in intestinal wall specimens to assess neuronal dysfunction in ARM patients.

Material and methods :

Thirty children having ARM were included in our study. In all the cases, a representative biopsy was received. The tissue sections were processed and wax blocks were prepared. Various histopathological changes were examined on routine H&E. Representative sections were further subjected to IHC staining for ganglion cells (calretinin), interstitial cells of Cajal (CD117) and nerve bundles (S-100 protein). Descriptive variables were analyzed to assess neuronal dysfunction in cases of ARM. Chi-square was used to compare the categorical values. P-value <0.05 was accepted as statistically significant.

Results :

Biopsies were studied for histological changes using H&E stain. The most frequently observed histological finding in mucosa was inflammation and congestion in 87% and 67% of cases respectively. Disrupted muscularis mucosa was observed in 60%, eroded mucosa in 57%, and hemorrhage in 40% of cases. Submucosal inflammation and congestion were most common finding observed in submucosa in 87% and 80% cases respectively. CD117 was used to demonstrate altered density and distribution of interstitial cells of Cajal (ICC) in cases of ARM. Majority of them belong to grade 2+ category (n=17, 57%) followed by grade 1+ (n=8, 17%) for ICC cells. Altered density and distribution of ICC was observed in ARM which was statistically significant (p=0.02).

Conclusion :

The malformed segments in ARM show various specific and non-specific histomorphological changes. Examination of H&E sections along with IHC stains evaluation can minimize need for repeated biopsies and unnecessary radical treatment. CD117 immunohistochemistry is reliable adjunctive test in evaluation of ICC in motility disorders of bowel. Calretinin is good marker for identification of ganglion cells. In ARM, density and distribution of ICCs is significantly altered which can explain postoperative dysmotility.

Giant Intrauterine Cystic Malformation of Thumb

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Ileal Trichobezoar Presenting as Intestinal Obstruction and Peritonitis

Trichobezoar is less common in boys. We are reporting a case of isolated ileal trichobezoars in a 4-year old boy causing intestinal obstruction and gut ischemia with perforation and peritonitis. The case was managed surgically with ileal resection and anastomosis. Postoperative period was uneventful.

Transverse testicular ectopia with scrotal hypospadias but without inguinal hernia - Case report of a rare association

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TTE associated with scrotal hypospadias but without inguinal hernia is an extremely rare anomaly and possibly has never been reported in literature.

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The diagnosis of TTE is usually considered when unilateral hernia and concurrent cryptorchidism of the contralateral side are present but it can also present without inguinal hernia as in our case.

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Presence of inguinal hernia should never be considered a prerequisite for a clinical diagnosis of TTE.

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In suspected cases, ultrasonographic evaluation, MRI of the pelvis and laparoscopy may be helpful in diagnosing this condition before surgery.

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Management is either trans-septal orchiopexy or extraperitoneal transposition orchiopexy.

Transverse testicular ectopia is an extremely rare anomaly, in which both the testis migrate towards the same hemiscrotum through the same inguinal canal. It is usually associated with other abnormalities such as persistent Mullerian duct syndrome, true hermaphroditism, inguinal hernia, pseudohermaphroditism, and scrotal anomalies; the association with inguinal hernia being the commonest. We, here, report a case of transverse testicular ectopia in a 12 years old boy having the ectopic testis in contralateral hemiscrotum without any inguinal hernia but having scrotal hypospadias with severe chordee. The diagnosis was made on clinical examination and confirmed on ultrasonography. Trans-septal orchiopexy was done for ectopic testis and hypospadias and chordee were managed by staged repair.

Gastrointestinal Duplication Presenting as Neonatal Intestinal Obstruction: An Experience of 15 Years at Tertiary Care Centre

Background: Gastrointestinal tract (GIT) duplications are one of the rare congenital anomalies and can occur in any portion of the gastrointestinal tract but are more commonly encountered in small intestine. The duplication cysts cause symptoms like abdominal mass and intestinal obstruction requiring surgery or may remain asymptomatic. We are reporting our 15 years’ experience duplication cysts presenting in neonates.

Methods: It is a retrospective study undertaken in the department of pediatric surgery between 2001 and 2015 for GIT duplications in neonates. Patients were analyzed for their antenatal diagnosis, age, sex, clinical diagnosis, investigatory approach, operative management and surgical outcomes.

Results: Total number of neonates, diagnosed with gastrointestinal duplication in the last 15 years, was 17. Male to female ratio was 3.3:1. The most common location was found to be the ileum occurring in 71% of cases. Apart from ileum, 2 cases of duodenal and 1 case each of gastric, colonic and cecal duplication cyst were encountered. Majority cases presented with sub-acute intestinal obstruction and were managed successfully by resection and end to end anastomosis. Associated gut atresia was found in 4 cases while 1 case was found to be associated with perforation of gut.

Conclusion: Gastrointestinal tract duplications often present with typical symptoms of gastrointestinal tract obstruction. Early diagnosis and management is required to prevent postoperative morbidity and mortality.

Giant Primary Epithelial Splenic Cyst in an Adolescent Girl

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Modified Gut Anastomotic Technique in Type III and Type IV Jejunoileal Atresias

BACKGROUND

Type III and IV jejunoileal atresias are associated with loss of significant length of the gut and can lead to short gut syndrome if further resection of proximal dilated gut is done. We modified the anastomotic technique so that proximal dilated segment of the gut is not resected as to prevent short gut syndrome.

MATERIAL AND METHODS

Medical Record of patients of Type III and IV jejuno-ileal atresias managed with modified anastomotic technique in our center during 5-years was reviewed.

RESULTS

Fifteen patients were managed with our modified technique. There were no anastomotic leak observed and there was 6% mortality seen in our modified technique.

CONCLUSION

We found less mortality and morbidity in our technique compared to recommended techniques described in literature.

Meckel's diverticulum in children: Our 12-year experience

BACKGROUND

Meckel's diverticulum (MD) is the one of the most common congenital malformation of gastrointestinal tract and has varied clinical presentations. We are presenting here our 12-year experiences with MD in children at tertiary care hospital in North India. It highlights the fact that isolated gangrene of MD can occur, and it is associated with increased morbidity.

MATERIALS AND METHODS

This retrospective study is conducted by analysing the medical records of the patients who were operated for MD in the last 12 years in paediatric surgery department at our hospital.

RESULTS

Sixty-five patients were operated for MD in study period; in this 52 were males and 13 were females with mean age of presentation 3.2 years. The most common presentation was intestinal obstruction seen in 86.1% (56 cases). Intestinal haemorrhage was seen in 4.6% (3 cases) and diverticulitis in 3% (2 cases). Perforation of the gut with peritonitis was present in 6.1% (four cases). Cause of obstruction was intussusception in 21.4% (12 cases), fibrous band connected to umbilicus in 17.8% (10 cases), volvulus in 17.8% (10 cases), kinking in 16.0% (9 cases), knotting in 14.2% (8 cases) and herniation of gut below in 12.5% (7 cases). Isolated gangrene of MD was present in ten cases with intestinal obstruction. The ectopic gastric mucosa was seen in three and pancreatic mucosa in two cases. Mortality and morbidity during the study were one and three cases, respectively.

CONCLUSION

MD may remain clinically silent for lifetime, or it may have life-threatening complications. In our series, intestinal obstruction and not the haemorrhage was the most common presentation. Isolated gangrene of MD with obstruction was present in significant numbers, which we failed to find in literature.

Neurenteric Cyst Presenting with Bleeding Per Rectum

Neurenteric cyst in the thoracic cavity may produce a myriad of clinical features. We report a 7-month-old girl who presented with significant bleeding per rectum. On imaging, a mediastinal cystic structure with air-fluid levels was evident with cervico-thoracic vertebral anomalies. The cyst was excised and histopathology showed intestinal mucosal lining with heterotopic pancreatic tissue confirming the diagnosis of neurenteric cyst.

Right Parotid Fibrolipoma: A Rare Lesion in a Child

Lipoma rarely involves parotid gland especially in children. An 11-year-old boy presented with right parotid swelling. Preoperative workup including CT scan and FNAC gave suspicion of parotid gland lipoma. The diagnosis was confirmed on histopathology after complete excision of the mass.

Vitellointestinal Duct Anomalies in Infancy

Background: Vitellointestinal duct (VID) or omphalomesenteric duct anomalies are secondary to the persistence of the embryonic vitelline duct, which normally obliterates by weeks 5–9 of intrauterine life.

Methods: This is a retrospective analysis of a total of 16 patients of symptomatic remnants of vitellointestinal duct from period of Jan 2009 to May 2013.

Results: Male to female ratio (M:F) was 4.3:1 and mean age of presentation was 2 months and their mode of presentation was: patent VID in 9 (56.25%) patients, umbilical cyst in 2(12.25%), umbilical granuloma in 2 (12.25%), and Meckel diverticulum as content of hernia sac in obstructed umbilical hernia in 1 (6.25%) patient. Two patients with umbilical fistula had severe electrolyte disturbance and died without surgical intervention.

Conclusion: Persistent VID may have varied presentations in infancy. High output umbilical fistula and excessive bowel prolapse demand urgent surgical intervention to avoid morbidity and mortality.

Digital Polypectomy: A Simple Technique for Rectal Polyps in Children

Excision, suture ligation and endoscopic snaring are the recommended methods of treatment for a juvenile rectal polyp. A successful experience of a simpler technique, digital polypectomy, in 218 cases is reported.

Sacral Rachipagus Parasite: A Case Report

We are reporting a case of sacral rachipagus parasite which was vaginally delivered as a large irregular mass attached to the sacral region by a vascular pedicle. This case was managed successfully by surgical excision of parasite.

Immature Gastric Teratoma in a Newborn: A Case Report

A case of immature gastric teratoma in a neonate is being reported here. The neonate was presented with abdominal mass and distension and managed with excision of mass; the patient is doing fine postoperatively.

Neonatal Duodenal Obstruction: A 15-Year Experience

Background: Congenital duodenal obstruction is one of the commonest causes of neonatal intestinal obstruction. We are presenting our 15-year experience by analyzing clinical spectrum and outcome in neonates with duodenal obstruction admitted at our center.Material and Methods: The hospital records of all neonates admitted with duodenal obstruction from June 2000 to June 2015 were reviewed. The patient records were analyzed for antenatal diagnosis, age, sex, clinical presentation, diagnosis, associated anomalies, surgical procedures performed; postoperative morbidity and mortality. We excluded from our study malrotation of gut associated with congenital diaphragmatic hernia and abdominal wall defects.Results: A total of 81 patients were admitted, out of which 56 were males and 25 were females. Polyhydramnios was detected in 24 (30%) pregnancies. Average birth weight was 2.1±1.0Kg and average gestational age was 38 (SD±1) weeks with 17 (21%) preterm neonates. Presenting features were vomiting in 81(100%) which was bilious in 81% and non bilious in 19%, epigastric fullness in 56 (69%) and dehydration in 18 (22%) and failure to thrive in 16 (19%). Most common cause of obstruction was duodenal atresia in 38 (46.9%), followed by malrotation of gut in 33 (40.7%), and annular pancreas in 4 cases. Depending upon site of location, infra-ampullary obstruction was the most common in 64 (79%), supra-ampullary in 9 (7.4%) and ampullary 8 neonates. Both duodenal atresia and malrotation of gut was present in 4 cases. X-ray abdomen was most commonly used investigation to confirm the diagnosis. All cases were managed surgically by open laparotomy. Eleven (13.5%) patients died due to sepsis and associated congenital anomalies.Conclusion: Congenital duodenal obstruction most commonly presents in early neonatal period with features of upper GIT obstruction like vomiting and epigastrium fullness as in our series. Early antenatal diagnosis and surgical interventions hold the key in achieving good outcome. Associated congenital anomalies, prematurity, sepsis and delayed presentation are the main risk factors for post-operative mortality and morbidity.

Neonatal Duodenal Obstruction: A 15-Year Experience

BACKGROUND

Congenital duodenal obstruction is one of the commonest causes of neonatal intestinal obstruction. We are presenting our 15-year experience by analyzing clinical spectrum and outcome in neonates with duodenal obstruction admitted at our center.

MATERIAL AND METHODS

The hospital records of all neonates admitted with duodenal obstruction from June 2000 to June 2015 were reviewed. The patient records were analyzed for antenatal diagnosis, age, sex, clinical presentation, diagnosis, associated anomalies, surgical procedures performed; postoperative morbidity and mortality. We excluded from our study malrotation of gut associated with congenital diaphragmatic hernia and abdominal wall defects.

RESULTS

A total of 81 patients were admitted, out of which 56 were males and 25 were females. Polyhydramnios was detected in 24 (30%) pregnancies. Average birth weight was 2.1±1.0Kg and average gestational age was 38 (SD±1) weeks with 17 (21%) preterm neonates. Presenting features were vomiting in 81(100%) which was bilious in 81% and non-bilious in 19%, epigastric fullness in 56 (69%) and dehydration in 18 (22%) and failure to thrive in 16 (19%). Most common cause of obstruction was duodenal atresia in 38 (46.9%), followed by malrotation of gut in 33 (40.7%), and annular pancreas in 4 cases. Depending upon site of location, infra-ampullary obstruction was the most common in 64 (79%), supra-ampullary in 9 (7.4%) and ampullary 8 neonates. Both duodenal atresia and malrotation of gut was present in 4 cases. X-ray abdomen was most commonly used investigation to confirm the diagnosis. All cases were managed surgically by open laparotomy. Eleven (13.5%) patients died due to sepsis and associated congenital anomalies.

CONCLUSION

Congenital duodenal obstruction most commonly presents in early neonatal period with features of upper GIT obstruction like vomiting and epigastrium fullness as in our series. Early antenatal diagnosis and surgical interventions hold the key in achieving good outcome. Associated congenital anomalies, prematurity, sepsis and delayed presentation are the main risk factors for post-operative mortality and morbidity.

Sacral Rachipagus Parasite: A Case Report

We are reporting a case of sacral rachipagus parasite which was vaginally delivered as a large irregular mass attached to the sacral region by a vascular pedicle. This case was managed successfully by surgical excision of parasite.

Neonatal Adrenal Hemorrhage presenting as Prolonged Hyperbilirubinemia

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Pure Esophageal Atresia without a Gap: An Unusual Variant

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Immature Gastric Teratoma in a Newborn: A Case Report

A case of immature gastric teratoma in a neonate is being reported here. The neonate was presented with abdominal mass and distension and managed with excision of mass; the patient is doing fine postoperatively.

Neonatal Intestinal Obstruction: A 15 Year Experience in a Tertiary Care Hospital

INTRODUCTION

Neonatal intestinal obstruction is the most common surgical emergency in a newborn requiring prompt intervention. There are only very few studies done in world regarding pattern of neonatal intestinal obstruction.

AIM

This study was conducted to see the aetiological spectrum of neonatal intestinal obstruction and to find out the problems and outcome of surgical management.

MATERIALS AND METHODS

This study was done retrospectively to include all operated cases of neonatal intestinal obstruction from June 2000 to May 2015 and various factors affecting outcome were analysed.

RESULTS

A total of 298 newborns were included in the study. Male-female ratio was 1.8:1. Gestational age was variable from 32 to 42 weeks (mean = 37.5 weeks) and birth weight from 1.4 to 3.5kg (mean= 2.25 kg). Mean age of presentation was 6 days with intestinal atresia (49.6%) as the commonest cause. Other causes were Hirschsprung (13%), Malrotation gut (11.7%), Meconium ileus (7.3%), patent VID (5%), duodenal obstruction (4%), duplication cyst (3.7%), obstructed hernia (2.7%) and others (2.7%). Mortality rate was 16.4% with sepsis both pre as well as post operative as the main cause of mortality.

CONCLUSION

The morbidity and mortality of neonatal intestinal obstruction has improved over last few years mainly due to antenatal detection, early intervention, meticulous resuscitation before surgery along with good NICU care.

Congenital Pyloric Atresia with Distal Duodenal Atresia- Role of CT Scan

The mainstay of diagnosis of congenital pyloric atresia is by plain X-ray of the abdomen showing a large gas bubble with no gas distally. But very rarely it can be associated with distal duodenal atresia when the baby may present as lump abdomen. In such a situation apart from the X-ray, another radiological investigation is needed to delineate the exact nature of the lump. Since the role of ultrasonography is limited in intestinal pathologies and contrast studies are not informative in atresias, the CT scan is the ideal choice. We had managed a case of pyloric atresia with similar presentation with preoperative CT scan.

Congenital Pyloric Atresia with Distal Duodenal Atresia- Role of CT Scan

The mainstay of diagnosis of congenital pyloric atresia is by plain X-ray of the abdomen showing a large gas bubble with no gas distally. But very rarely it can be associated with distal duodenal atresia when the baby may present as lump abdomen. In such a situation apart from the X-ray, another radiological investigation is needed to delineate the exact nature of the lump. Since the role of ultrasonography is limited in intestinal pathologies and contrast studies are not informative in atresias, the CT scan is the ideal choice. We had managed a case of pyloric atresia with similar presentation with preoperative CT scan.

Exomphalos Major Associated with Thoracic Teratoma and Hamartoma of Left Leg: A Rare Association

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Complicated appendicitis: analysis of risk factors in children

BACKGROUND

Acute appendicitis (AA) is the most common surgical emergency in childhood. The risk of rupture is negligible within the first 24 h, climbing to 6% after 36 h from the onset of symptoms. Because of difficulty in accurate diagnosis of AA a significant number of children still are being managed when it is already perforated. There is always a need to make an early diagnosis of AA and to find out the risk factors associated with development of complication in this condition.

PATIENTS AND METHODS

A total of 102 patients with a clinical diagnosis of AA were admitted during the study period. On admission, a good clinical history and proper physical examination was performed. All the eligible patients who finally diagnosed clinically as having AA were planned for emergency open appendectomy. The removed appendix was sent for histopathological examination in all the study subjects.

RESULTS

Out of 102 cases, 93 cases were histopathologically appendicitis, rest nine cases showed no evidence of inflammation so the rate of negative appendectomy was around 9%. On histopathology normal appendix was found in nine patients (8.9%), AA in 71 patients (69.6%), complicated appendicitis (CA) which includes perforated and gangrenous appendicitis was present in 22 patients (21.5%). Perforations were more common in patients who were younger than 5 years. >60% patients presented with CA when the duration of pain was >72 h. Presence of appendicolith increased the probability of CA.

Congenital spigelian hernia and cryptorchidism: another case of new syndrome

Spigelian hernia (SH) is rarely seen in pediatric age group and is usually associated with cryptorchidism on the same side; termed as a syndromic association of the defect in the Spigelian fascia and absence of gubernaculum and inguinal canal. The absence of the inguinal canal has surgical implication as to placement of the undescended testis into the scrotum. A 3-month-old baby presented with spigelian hernia and ipsilateral impalpable testis. The spigelian hernia was repaired and undescended testis which was present in abdominal wall layers was brought to scrotum with cord structures anterior to external oblique muscle.