Dictation <CLINICIAN_NAME>: After induction of anesthesia and intubation by the anesthesia colleagues, entry with the small bore tube and inspection of the hypopharynx. An exophytic process measuring approx. 2-3 cm can be seen at the entrance to the piriform sinus on the medial and anterior side. The tip of the piriform sinus is free. This shows the exophytic mass measuring approx. 2-3 cm. It is located on the anterior and medial side wall of the piriform sinus. The tip is free. The lateral wall is also free. The process also extends into the postcricoid region. Adjustment of the process with the spread laryngoscope and activation of the laser and microscope. Start cutting around the tumor on the medial side wall and gradually remove it. Hemostasis is achieved using monopolar coagulation or vascular clips. To be on the safe side, another resection is performed on the medial wall, as the margin was relatively narrow after removal of the tumor in toto. Both are suture-marked for the frozen section. The frozen section still shows an invasive carcinoma in the mediocaudal area. A generous resection is performed here, including a margin sample, which is again sent to the frozen section. Final R0 situation. This results in a large wound area. Therefore decision to perform a tracheostomy. PEG placement using the thread pull-through method. Successful with good diaphanoscopy. Neck dissection on the right in the meantime. Externally a 5-6 cm metastasis breaking through the skin at level Va to b. Skin incision at the anterior edge of the sternocleidomastoid muscle and in the area of the metastasis around the mass. Exposure of the platysma in the anterior upper area. Formation of a platysma flap. Exposure of the submandibular gland. Exposure of the sternocleidomastoid muscle. This also shows that the metastasis under the skin also infiltrates the sternocleidomastoid muscle in the cranial region. For this reason, the sternocleidomastoid is deposited in the caudal region at the base and the metastasis is deposited from caudal to cranial, sparing the cervical vascular sheath. The metastasis also infiltrates the cervical plexus, which must be completely removed except for a few small branches. The vagus nerve remains intact as it can be pushed away by the tumor. The border cord cannot be completely spared from the tumor. The accessory nerve is also removed. Ultimately, the hypoglossus remains at the top. During dissection, the subclavian vein is torn in the caudal area. This resulted in severe bleeding, which could be sutured over. The result is an hourglass-shaped structure that leads to narrowing of the vein but is still pervious. During the treatment of the subclavian hemorrhage, the outlet of the internal jugular vein was also torn, which ultimately had to be removed. However, deeper accompanying veins could be preserved. V. Bezas: Neck dissection on the left: Skin disinfection on the left and injection of 6 ml mixed solution of Ultracaine with 2% Suprarenin added in the area of the anterior border of the sternocleidomastoid muscle. Sterile washing and draping. Creation of a skin incision on the anterior border of the sternocleidomastoid muscle. Dissection in depth and identification of the platysma. This is cut sharply. Now lift off a subplatysmal flap anteriorly and posteriorly. Further dissection in depth and identification of the superficial cervical fascia. Now identify the external jugular vein and auricular nerve. The great auricular nerve is completely spared and the external jugular vein is coagulated and cut. Now identify the sternocleidomastoid and dissect in depth along the muscles. First dissection in the level II b area until the digastric muscle is identified. Now dissect further along the digastric muscle until the accessor nerve is identified. Tissue above the accessorius nerve is sharply separated and the remaining tissue from level II b is pulled under the accessorius. Further dissection in the area of level II a up to the identification of the facial vein. Here a resection is performed below the submandibular gland. The marginal ramus nerve and facial nerve are not exposed during the preparation. Now clear Level II a until the hypoglossal nerve is identified. The hypoglossal nerve and internal carotid artery are exposed and spared. Now dissect further downwards along the sternocleidomastoid muscle to below the omohyoid muscle. Dissection further laterally up to the identification of the cervical plexus. Further dissection anteriorly above the cervical plexus and prevertebral cervical fascia. Sharp separation of the fatty tissue in level IV and dissection now along the common carotid artery. The fascia of the cervical vascular sheath is largely spared here. Now lift the preparation cranially and complete the dissection in level IV and level III above the internal jugular vein. Further dissection along the omohyoid muscle and infrahyoid muscles. The complete neck dissection is removed as one piece and sent for histological analysis. Careful hemostasis using ligatures and bipolar forceps. A size 10 Redon drain is placed and the wound is closed step by step once the bleeding has stopped completely. <CLINICIAN_NAME>: Lifting of the pectoralis major flap. Measurement of the defect. This results in a 5x7 cm defect that needs to be covered on the neck. The skin island medial to the nipple is configured accordingly. Creation of a skin bridge in the area of the theoretical delto-pectoral flap. Lifting of the skin island from the thoracic wall while protecting the pectoralis minor muscle. Locate and expose the vascular pedicle. Medial separation of the pectoralis major and lateral separation of the pectoralis major from the attachment to the humerus. Finally, most of the muscle is removed. The pedicle is palpable the entire time and the skin island is well supplied with blood. Pull the flap through the skin bridge and fit the graft so that a large muscle patch is positioned in the area of the pharynx. This muscle patch is fixed with sutures and the skin island can be inserted into the skin defect and sutured there. Two Redon drains were previously inserted in the chest area and one in the neck area. Two-layer wound closure in the neck and chest area. At the end, a tracheotomy was created using the visor technique. Insertion into the trachea between the 1st and 2nd tracheal cartilage and creation of a mucocutaneous anastomosis. Patient goes to the intensive care unit for postoperative monitoring. Please set up a diet on the 7th postoperative day without performing an X-ray pre-swallow. Presentation of the patient at the tumor conference to plan adjuvant radiochemotherapy.  