Case Presentation

A 97-year-old man presented with acute small bowel obstruction due to painful bilateral inguinal hernias, which were demonstrable both clinically and radiographically (Fig. 1). His medical history included chronic hernias, stroke, ischaemic heart disease, previous myocardial infarction, and osteomyelitis. On examination, his abdomen was distended and diffusely tender, most notably within the left inguinal region. Initial laboratory tests showed a normal white cell count of 9300 × 109/L (reference range 4000–11,000 × 109/L) and a raised C-reactive protein level of 25 mg/L (reference range 0–10 mg/L).

Fig. 1
figure 1

A supine plain abdominal radiograph of a 96-year-old man presenting with acute abdominal pain. The film shows non-specific gaseous bowel loop dilatation

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An urgent thin-slice computed tomography confirmed small bowel dilatation and right inguinal and left inguinoscrotal hernias (the level of transition at its average-size neck). Each hernia contained the ipsilateral bowel parts such that the caecum/appendix was visible within the right hernia (red arrows) and the distal ileal loops could be seen within the left hernia (white arrows). The terminal ileum (yellow arrowheads) crossed horizontally to connect both hernias and was enveloped in an outward pouch of the suprapubic inferior abdominal wall in a manner reminiscent of the “Hosentürl” front-flap typically associated with traditional “Lederhosen” (Fig. 2; cine clips of axial and coronal supplementary files).

Fig. 2
figure 2

Selected axial and coronal images of an enhanced CT scan abdomen/pelvis of a 96-year-old man showing small bowel dilatation and right inguinal hernia containing caecum/ileocaecal junction (red arrows) and terminal ileum horizontally crossing (yellow arrowheads) to enter the left large inguinoscrotal hernia (white arrows). Terminal ileum is enveloped within an outward pouch of the suprapubic inferior abdominal wall. Overall appearance mimics the front-flap (Hosenlatz or “Hosentürl”) found in the traditional costume “Lederhosen” as worn in southern Germany and Austria

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The larger left inguinoscrotal hernia contained free fluid surrounding prominent small bowel loops with a mildly oedematous mesentery. No discernible features of bowel perforation, ischaemia, or pneumatosis intestinalis were seen. The unique simultaneous arrangement of the hernial sac contents was perceived and interrogated with interest from the imaging perspective. However, given the marked frailty of the patient and his multiple cardiovascular comorbidities, he was deemed high risk for surgery and thus underwent a trial of manual hernia reduction, which was successful. The patient’s blood investigations and vital signs remained stable throughout admission, and he then returned to his nursing home with follow-up plans and without further complications.

Conclusions

Nowadays, the management of an acute abdomen includes the exclusion of complicated abdominal hernias. Enhanced CT scans offer numerous visualised anatomical details sufficient to delineate structural wall and bowel content within hernial sacs [1, 2]. Practically, clinicians and imaging specialists are required not only to detect the type and location, but also to further assess for potential complication and prognosis of hernias [3]. Therefore, in addition to conveying information on the location and content of hernias, referring to the applicable eponymous term could complement the reporting quality and signpost to an anticipated management plan, accordingly [1].

By reviewing literature, a comprehensive list of different eponymous types of hernia has been composed below (Table 1) [4,5,6,7,8,9]. In total, there are known 36 eponymous hernia types identified with the majority named after physicians, surgeons, anatomists, or pathologists. It is worthwhile mentioning that may be a handful eponyms are still known and taught in common surgical practice.

Table 1 List of different eponymous types of hernia from literature review
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Interestingly, pantaloon hernia is described as an ipsilateral concurrent direct and indirect hernia, each bulging on either side of the inferior epigastric vessels [10]. Likewise, this reported case is another mimic to a clothing or costume item perceived to resemble the front-flap of a “Lederhosen”. Bilateral inguinal and inguinoscrotal hernias are not uncommon, but the unique combined arrangement of both hernial sac contents demonstrates a different peculiar appearance that equally warrants precise imaging interrogation and could benefit from a descriptive term for educational illustration.