Pharyngoscopy performed again before the start of the operation: insertion of the small bore tube. As described above, an approx. 3 x 2 cm large mass can be seen in the right hypopharynx, which was positively biopsied as a squamous cell carcinoma. The tumor appears to be resectable by lateral pharyngotomy. The PEG is now initially inserted: the esophagoscope is inserted into the stomach. Due to the thickness of the subcutaneous layer, conditions are much more difficult. Nevertheless, a clear diaphanoscopy can now be seen when pressure is applied with the finger. Clear conditions under sonographic control. No liver or intestinal loops in the abdominal wall. Placement of the PEG with the thread pull-through method in the usual way. No bleeding. Primary wound dressing on the abdomen. Intraoperative administration of 250 mg SDH. Now infiltration anesthesia in the area of the right neck. First incision of a platysmal flap and careful dissection of the platysma further cranially. The sternocleidomastoid muscle is also exposed in depth. Further dissection of the platysmal flap over the submandibular gland in a cranial direction. Now dissection of the internal jugular vein and facial vein in depth. Very difficult dissection conditions. A large metastasis infiltrates the sternocleidomastoid muscle. For this reason, part of the muscle must be sharply separated from the metastasis. Finally, the internal jugular vein can be freed from the metastasis. Deep dissection of the vagus nerve and the external and internal carotid arteries as well as the accessorius nerve. Expose the posterior digastric venter muscle. Now complete the posterior neck by clearing out the accessorius triangle and dissecting the mass caudally to supraclavicular. Separate the soft tissue there and cut around it. Finally, dissection of the venous angle. Exposure of the hypoglossal nerve. Removal of the capsule of the submandibular gland. The previously described metastasis is now also completely separated from the facial vein. The vein remains intact. Dissection of the superior thyroid artery and completion of the neck preparation on the right with removal of all soft tissue and lymph nodes. Now proceed to the left. Here too, skin incision at the anterior edge of the sternocleidomastoid muscle. Dissection of the muscle in depth after cutting through the subcutaneous tissue and platysma. Exposure of the internal jugular vein and the external and internal carotid arteries as well as the vagus nerve. Exposure of the accessorius nerve and the posterior digastric venter muscle. Now dissect the posterior neck preparation from cranial to caudal. Protect the cervical plexus. Set down caudally after repositioning. Now dissect the submandibular gland. Remove the capsule. Dissection of the hypoglossal nerve and completion of the neck preparation anteriorly, including the capsule of the submandibular gland and the soft tissue in front of and above the common carotid artery. Perform the tracheotomy. Median skin incision for this. Dissection of the subcutaneous tissue and the infrahyoid musculature. Difficult dissection conditions due to the very deep larynx. Exposure of the thyroid isthmus. Undermining, cutting through and perforating it. Exposure of the cricoid cartilage. Insertion between the 1st and 2nd tracheal cartilage. Creation of a Björk flap and epithelialization of the tracheostoma. Relatively high tension due to the deep trachea. Re-intubation of the patient. Now turn back to the tumor side on the right and skeletonize the larynx on the right side or the thyroid cartilage. Enter the pharynx. The tumor becomes visible. This is also clinically incised in healthy tissue. It reaches up to the arytenoid cusp. Extremely difficult dissection conditions here. It is finally possible to resect the entire tumor from cranial to caudal, including part of the larynx and half of the thyroid cartilage on the right. Removal of marginal samples. These are found to be tumor-free. Extensive hemostasis with H2O2 and bipolar coagulation. Now perform the pharyngeal suture. The previously prepared platysmal flap is not required. Primary wound closure can be performed. Invert the sutures from caudal to cranial. Multi-layer wound closure. Mobilize the right thyroid gland and suture the thyroid gland over the pharyngeal suture again. Extensive hemostasis in the area of the right neck. Irrigation with H2O2. Irrigation with H2O2 and NaCl on the left side as well. No more bleeding. Insertion of a Redon drain on the left and right side. Subcutaneous sutures, skin sutures and wound dressing. The platysmal flap is resected and primary skin closure can be achieved on the right side by adapting the wound edges. Finally, an 8-gauge Rügheimer cannula is inserted again. The patient goes to the intensive care unit extubated or awake for monitoring. Further administration of Unacid over the next few days. No bleeding at the end of the operation, no other special features. The tumor and the neck specimen on both sides are sent for definitive histology.  