After induction of anesthesia and intubation by the anesthesia colleagues, another pharyngoscopy/laryngoscopy is performed to search for the primary ear. After inspection of the inconspicuous oral vestibule, the small bore tube is inserted under dental protection. Inspection and palpation of the oral cavity, which is also unremarkable. Now inspection of the oropharynx. This is inconspicuous, especially in the area of the tonsil regions and the base of the tongue. Adjustment of the endolarynx and the subglottic region. No evidence of primarius here either. With an inconspicuous esophageal entrance and left piriform sinus, a circumscribed, centrally ulcerated lesion measuring approx. 1 to 1.5 cm with a raised marginal wall is found in the area of the medial wall of the right piriform sinus. A representative sample is taken and a frozen section is made. This shows a basaloid, poorly differentiated squamous cell carcinoma, thus confirming the primary. Due to the extensive metastasis extending close to the pharyngeal wall, primary transcervical resection is indicated. The PEG tube is then inserted. This is done with the gastroscope under laryngoscopic control. Easy to see through to the stomach. Here, with excellent diaphanoscopy, problem-free puncture of the stomach. The PEG tube is then inserted using the usual thread pull-through method. The patient is then positioned. First turn to the neck dissection on the right side. Here the lymph node metastasis has grown extensively into the skin and is partially open. Incision around the skin area with a safety margin. Separation of the skin and extension of the skin incision cranially and caudally. Separation of the sternocleidomastoid muscle in the case of extensive infiltration. Exposure of the internal jugular vein and removal. In the case of clear cranial infiltration, expose and secure the common carotid artery and vagus nerve. Later resection of the omohyoid muscle. Cranial dissection of the metastasis with subtotal involvement of the cervical plexus roots. Inclusion of paravertebral musculature. Resection on all sides in .............. Infiltration of the submandibular gland, which is also resected. Here also clear infiltration and subsequent resection of the ramus marginalis mandibulae. Detachment of the metastasis on the mandible, taking the periosteum with it, no infiltration here. The accessor nerve is no longer visible in the case of extensive infiltration. Infiltration of the soft tissue up to the paralaryngeal area. Clear infiltration of the hypoglossal nerve, cranial also infiltration of the lingual nerve, but here no enoral growth. Careful dissection in the area of the carotid bulb, here the external carotid artery can be seen walled in by tumor tissue shortly after the exit. Skeletonization of the external carotid artery. Tumor tissue is clearly visible on the vessel, so here it is removed as far as possible at the bulb, here taking a marginal sample, but without the possibility of further resection. Careful free dissection and protection of the internal carotid artery, which is in contact with the tumor over a long distance, here also no further possibility for resection, but also no reliable indication of tumor invasion, therefore RX situation at this point. Cranial dissection, separation of the internal jugular vein cranially. Separation of the digastric muscle during infiltration and resection of the metastasis macroscopically in toto. If there is close contact with the cranial part of the skin, a resection is performed here, otherwise in sano conditions on all sides in the area of the skin. The resectate is sent for definitive histology. Later clearing of the transition from level I b to level I a, here further macroscopically clearly conspicuous nodules. The focus is now turned to the primary tumor region. Circumscribed skeletonization of the laryngeal skeleton. Entering the lateral pharyngeal wall, widening, exposing the piriform sinus. Release of the piriform sinus. Now a good overview of the tumor tissue. Cut around with a safety margin. Defect of the medial piriform sinus wall measuring approx. 2 x 2 cm in total. Resection defect up to the anterior piriform sinus wall, otherwise intact mucosa on all sides. The resectate is sent in thread-marked for frozen section diagnostics and appears R0-resected on the specimen. If the mucosa is sufficient and healthy, the primary closure of the pharyngotomy is performed, followed by relining with muscle tissue. Now neck dissection on the left. To do this, make a skin incision on the anterior edge of the sternocleidomastoid muscle. Cut through skin and subcutaneous tissue. Dissection of the platysma. Exposure of the sternocleidomastoid muscle, omohyoid muscle. Release of the submandibular gland with removal of the caudal capsule. Exposure of the digastric muscle. Removal of the anterior neck preparation with careful protection of the facial vein, the cervical vein, the superior thyroid artery and the hypoglossal nerve. Free preparation of the internal jugular vein. Overall, macroscopically conspicuous nodules on the vein. Exposure of the accessor nerve. Protection of the nerve and clearing of the accessorius triangle. Clearing of level V up to the transition to V b with careful protection of the cervical plexus branches, here some enlarged nodes, but not necessarily suspicious macroscopically. Finally, careful wound inspection and, in dry wound conditions, after wound irrigation with Ringer's solution, insertion of a 10-gauge Redon drain and careful, two-layer wound closure. Subsequently turn to tracheotomy, due to the extended radical neck dissection of the right side and potentially considerable risk of swelling due to the extent of the lymph node dissection. Horizontal skin incision below the cricoid cartilage. Exposure and transection of the infrahyoid muscles and exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea. Insertion between the 2nd and 3rd tracheal ring and subsequent insertion of the tracheostoma in the usual manner. Subsequent easy transfer to a size 8 low-cuff cannula, which is suture-fixed. At the same time, a pectoralis major flap was elevated from the right. After measuring the cutaneous defect in the area of the right neck skin, a 9 x 5 cm area of skin was lifted. Paramammary, broad-based lifting with subtotal lifting of the pectoralis major muscle. Careful subfascial release of the muscle. Exposure of the pectoralis minor muscle. Identification of the pedicle vessel and, while protecting the pedicle vessel, elevation of the flap, cranial tunneling and tension-free insertion into the neck defect, relining of the pharynx, the pharyngeal suture and adequate coverage of the neck skin afterwards. Insertion of 10 Redon drains and careful, strong, multi-layered wound closure. Subsequent completion of the procedure without any indication of complications. Conclusion: Intraoperatively confirmed and R0-resected cT1 hypopharyngeal carcinoma in the area of the medial piriform sinus wall on the right as primary in cN3 neck status right, here extended radical neck dissection with resection of the external carotid artery, the hypoglossal nerve, the ramus marginalis mandibulae, the lingual nerve and the border cord. Due to the long-distance contact with no possibility of resection in the area of the internal carotid artery, an RX situation can be assumed in the cervical area, which is why adjuvant therapy should be escalated here. Postoperatively, please perform an X-ray gruel swallow on the 10th day, followed by decannulation depending on the current prognostically unclear swallowing function.