Lederhosen Hernia: First Description and Literature Review

Etymologically, hernia means “to protrude or to bud”. Abdominal wall hernias are frequent findings in adult and children imaging. Hernias are described by grading the size of their sacs as well as detailing their coverings and contents. Clinically, hernias are classified based on their reducibility, either by the experienced surgeon or by the patient, into reducible or irreducible. Pathologically, they vary in their potential to be obstructed, inflamed, or strangulated. A crucial part of managing any hernia is to interpret the imaging features in order to classify its type and assess for complications. Ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are the most recommended imaging modalities. New generations of CT scans play an important role in elective and emergency hernia management. CT scans offer high reliability and sensitivity due to their easy accessibility, fast acquisition speed, higher resolution, and three-dimensional multiplanar reconstruction (3D-MPR). One of the most interesting aspects about hernias is their historically associated nomenclatures commonly published and used in medical education and surgical practice to specifically diagnose different hernia types. Those nomenclature terms (adjective or physician names), rather than anatomical regions, are by far the longest list of nomenclatures known to a single medical condition. Purposefully, the terms are essential for the identification of hernias by remembering and depicting their anecdotes. Similarly, the case presented here, supported by CT still/cine figures, introduces a new subtype of bilateral inguinal hernias where communicating hernial content and location are reminiscent of a “Lederhosen”.

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 × 10 9 /L (reference range 4000-11,000 × 10 9 /L) and a raised C-reactive protein level of 25 mg/L (reference range 0-10 mg/L).
An urgent thin-slice computed tomography confirmed small bowel dilatation and right inguinal and left inguinoscrotal hernias (the level of transition at its averagesize 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).
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.
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.

Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of interest.
Ethical Approval All images/cines prepared were anonymised prior to submission (courtesy of Nottingham University Hospitals NHS Trust).
No personal or confidential patient data used in composing this report.
Informed Consent A publication consent was obtained from the patient's next of kin.
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