The internal ring is freed from attachments, and evidence of a hernial sac is sought. If no indirect hernial sac is found, a small crescent reflection of peritoneum (processus vaginalis) is visible proximally. When an obvious hernial sac is found, it is freed by blunt and sharp dissection. When the sac is large, it can be filled with gauze sponge to provide counterpressure, which simplifies the pushing away of other tissues. The sac is opened and the index finger inserted medially under the inferior epigastric vessels in an effort to determine the presence or absence of a direct hernial defect. The neck of the hernial sac is freed from the surrounding tissue. Following this, the sac is ligated (Figure 2). Some believe an effort for a high ligation of the sac is unnecessary. If a lipoma of the cord is found, it is carefully excised, but the cord is not stripped of interstitial fat. Even large sliding hernia sacs can be freed and reduced without opening the sac.