Introductory consultation with the anesthesia department. Induction of anesthesia by the anesthesia colleagues. Pharyngoscopy and laryngoscopy again: insertion of the size B small bore tube. A small exulcerated tumor can be seen in the area of the anterior piriform sinus wall up to the border of the lateral wall. However, this shows a deep ulcer, so that a risk-free laser resection ultimately does not appear to be possible with pulsations on the lateral wall. The decision was therefore made to proceed transcervically. Initial PEG insertion: insertion with the flexible esophagoscope. Advance into the stomach. After creating the diaphanoscopy and sterile covering of the abdomen, insertion of an abdominal wall probe using a typical technique in a typical manner. Sterile fixation to the abdominal wall. Repositioning for neck dissection and tumor resection. The patient is also prepared for radial lobectomy. Therefore, all relevant surgical areas are covered. Injection of Ultracaine 1% with adrenaline 10 ml into both sides of the neck. Start with neck dissection level II to V on the right: skin incision in typical manner. Exposure of the sternocleidomastoid muscle. Exposure of the digastric and omohyoid muscles and the infrahyoid muscles. Dissection of the fat-lymph node package. Exposure of the cervical vascular sheath. Exposure of the internal jugular vein, facial vein. Exposure of the internal/external carotid artery, superior thyroid artery and facial artery. Exposure, displacement and at the end of the operation re-embedding of the hypoglossal nerve, vagus nerve, accessorius nerve, branches of the cervical plexus and the border cord in the sense of a neurolysis. Lymph nodes are firmly attached to the vessels in the upper area, but can be dissected, even in depth, and dissected from the border cord. Level II to V dissection is performed while preserving all structures. Neck dissection on the left: This is performed in the same way as on the opposite side. Here too, all structures are preserved as on the opposite side. Then tumor resection: Exposure of the hyoid bone, which is also resected laterally. Exposure and resection of the upper horn of the larynx. Mobilization of the pharyngeal tube. Entering the pharynx just below the hyoid bone at the level of the epiglottis. The tumor can be visualized. This is resected with a safety margin of at least 1 cm on all sides, macroscopically in healthy tissue. Resection includes the anterior piriform sinus and parts of the lateral wall. As the tumor has its deepest ulcer basally in the direction of the thyroid cartilage, the lateral thyroid cartilage is also resected and is attached basally to the specimen. The superior laryngeal nerve can also not be preserved in direct contact with the tumor. The specimen is then marked with sutures and sent in. In addition, a marginal sample is taken from the medial area. A strip is taken from the area of the arytenoid fold down to the piriform sinus. The frozen section shows that the tumor has been removed from the healthy area. However, carcinoma in situ can still be seen in some places in the medially removed marginal sample. A further resection is recommended here. Therefore, another resection of an almost 1 cm wide mucosal strip from the area of the arytenoid fold is performed, whereby the border to the postcricoid area is already reached. The frozen section still shows very clear carcinoma in situ infiltrates in most areas with a transition to microinvasive carcinoma in some places. Based on the overall situation, field carcinomatization can now be assumed in the entire hypopharyngeal region. At the very least, this cannot be ruled out. A further resection in the direction of the postcricoid area would in any case be accompanied by significant dysphagia and possibly necessitate a laryngectomy. However, this was not discussed in detail with the patient in advance. Therefore, the decision was made not to perform a further resection. The pharynx is closed using 3-0 Vicryl single button sutures, whereby the mucosa is closed directly in the lower area to the piriform sinus, and in the upper area the mucosa is sutured to the inside of the residual thyroid cartilage. In the upper area, the mucosa is sutured again. Pharyngeal muscles are stitched over this and sutured around the thyroid cartilage to the infrahyoid muscles, suprahyoid muscles or hyoid bone. This results in a stable closure. Extensive irrigation of the entire surgical area. Careful hemostasis. Layered closure of the wound on the left with insertion of a Redon drain, on the right with insertion of two Redon drains. Application of a wound and pressure dressing on both sides. Creation of a tracheotomy: Subcutaneous tissue is prepared via a Kocher collar incision in the typical manner, veins are ligated. The thyroid isthmus is then severed. Exposure of the trachea. Thyroid isthmus is cut off. The trachea is opened like a visor flap at the typical location and an epithelialized tracheostoma is created. Finally, an 8 mm tracheal cannula is inserted after removal of the laryngectomy tube. Application of a wound dressing. Subsequent completion of the procedure without complications. Final consultation with the anesthesia department. The patient is transferred to the intensive care unit for monitoring. Here, please continue the antibiotic treatment that was started preoperatively with Unacid for a further week. Nutrition via the inserted PEG tube. Wait for the final histology. According to the current state of knowledge, field carcinomatization is present, particularly in the direction of the postcricoid area, which would ultimately necessitate a laryngectomy in the event of surgical treatment. However, due to the still microinvasive carcinoma parts, postoperative radiochemotherapy should also be discussed.