After an initial consultation with the anesthesia colleagues, the patient is intubated and the tumor is inspected again after insertion of the mouth blocker. The tumor was found to be the same size as in the previous panendoscopy. The patient is then repositioned and tumor resection begins from the soft palate. Here, the tumor does not reach the uvula so that it can be preserved. However, the anterior and posterior palatal arches must be partially removed. Careful coagulation, dissection and partial ligation of the vessels are then performed. Dissection from cranial to caudal. The main tumor mass then begins in the area of the lower tonsil pole and moves into the hypopharynx and from there onto the pharyngoepiglottic fold. The dissection is performed in the layers of the parapharyngeal musculature. Larger arterial vessels are cut several times during dissection if there is a clear tendency to bleed. Dissection is now carried out in the direction of the pharynx. In the area of the glossotonsillar groove, the tumor extends slightly onto the base of the tongue, so that a partial resection must also be carried out in the area of the base of the tongue and the tonsil at the base of the tongue. Careful hemostasis is also required here. It now appears that the tumor is draining at the level of the hypopharynx and piriform sinus entrance and can be deposited here at the pharyngoepiglottic plica. A separate margin sample is then taken in the area of the caudal margin. The corresponding area on the tumor specimen is also marked with a thread. This margin sample and the tumor specimen are then sent for frozen section assessment. However, this shows that the marginal specimen in the area of the deposit margin at the base of the tongue cannot be assessed due to thermal alterations. The sedimentation margin sample in the area of the caudal sedimentation margin shows broad tumor infiltrates, so that the decision is made to reposition the patient and use the spreading laryngoscope to adjust the area of the hypopharynx and the caudal sedimentation area. This is done easily after insertion of the mouthguard. Then pre-segmentation under vision up to the hypopharynx and adjustment of the caudal tumor bed. The surgical microscope and CO2 laser are now added so that this area can be resected again over a large area with the laser. Again, careful bipolar coagulation of larger vessel stumps. A marginal sample is then taken again. Both the resected specimen and the marginal specimen are then sent again for frozen section assessment. The findings here are that broad tumor infiltrates can again be found in the post-resectate. The marginal sample is again strongly thermally altered, but shows no tumor infiltrates. However, due to the poor findings, a second margin sample was taken, which was then designated as margin sample caudal no. 3 and was again sent for frozen section. This is then found to be tumor-free, so that an R0 resection of the tumor can now be assumed. Therefore, after repeated careful hemostasis, the PEG tube is inserted. To do this, the flexible esophagoscope is inserted into the esophagus and the tube is advanced under visualization into the stomach, where the PEG tube can then be placed without difficulty if the diaphanoscopy is positive and the tent phenomenon is positive. This is done using the typical thread pull-through method. The patient is then mirrored back and the esophagus is carefully inspected again, where the mucosa is found to be normal. The patient is then repositioned for the tracheostomy. Inject local anesthetic with adrenaline on both sides of the neck as well as prelaryngeally and tracheally. A door incision is then made pretracheally and dissected in layers in depth. Pre-tracheal vein branches are then partly ligated and partly bipolar coagulated. The pretracheal musculature is then exposed, separated in the midline and dissected apart. Further layered dissection in depth and exposure of the thyroid isthmus. This is then undermined and, after separation of the isthmus, is ligated on both sides. Then expose the anterior surface of the trachea. Now enter the trachea between the 2nd and 3rd tracheal clasp. Dissection of the Björk flap. Then circular suturing and epithelialization of the tracheostoma. Then reintubation, which is also possible with an 8 mm tube. Now reposition the patient for neck dissection on the right side. First make a skin incision along the front edge of the sternocleidomastoid muscle. Then dissect in layers in depth after cutting through the platysma. Expose the cervical vascular sheath. In the cranial area, exposure and neurolysis, displacement and re-embedding of the auricularis magnus nerve. Then further dissection of the cervical vascular sheath in layers as far caudally as the omohyoid muscle and cranially to the digaster muscle. Here, lateral exposure of the accessorius nerve. Here too, neurolysis, displacement and re-embedding of the nerve. Then complete release of the lateral neck preparation from the accessorius triangle caudally, in the sense of levels II and III as well as IV and V. There is a lymph node conglomerate in the area of the vein angle, but this can be easily dissected away from the vein so that it can be well preserved. During dissection of the cervical vascular sheath, neurolysis, displacement and re-embedding of the vagus nerve. Subsequently, in the area of the hypoglossal triangle during preparation of the level Ib neck specimen. Then protection of all branches of the internal jugular vein and external carotid artery. Here also neurolysis, displacement and re-embedding of the hypoglossal nerve. The cervical profunda is also completely preserved during dissection and is also relocated and re-embedded in its course after neurolysis. Now dissection of the caudal medial neck preparation, where no conspicuous lymph nodes are found. All branches of the cervical plexus were also preserved during dissection of the lateral neck specimen. After significant arterial bleeding occurred intraoperatively in the area of the tumor resection, the decision was made to cut off the external carotid artery above the exit of the superior thyroid artery, which was then carried out without any problems after the external carotid artery had been clearly identified. The wound is then carefully irrigated. In summary, this results in a level Ib-V neck dissection. A Redon drain is then inserted. Two-layer wound closure and dressing. The patient is then repositioned for neck dissection on the left side. Here too, skin incision along the sternocleidomastoid muscle on the left side. Subsequent dissection in layers in depth. In the cranial area, neurolysis, exposure and protection of the auricularis magnus nerve, after displacement of the nerve cranially. Further layered preparation in depth after cutting through the platysma. Exposure of the cervical vascular sheath. Exposure of the caudal and cranial borders. Exposure, neurolysis and displacement as well as re-embedding of the accessorius nerve. Then, here too, release of the lateral neck preparation from the accessorius triangle caudally. Dissection of the venous angle and hypoglossal triangle. In doing so, protect all branches of the internal jugular vein and external carotid artery. Also exposure, neurolysis, displacement and re-embedding of the hypoglossal nerve with the cervical profunda. Then complete dissection of the anterior neck preparation. Here too, the branches and branches of the external carotid artery and internal jugular vein are preserved. During dissection, the vagus nerve is also exposed, neurolyzed, displaced and re-embedded. Here, too, careful hemostasis was performed. Overall, this also results in a level Ib-V neck dissection. A Redon drain is then inserted and the wound is closed in two layers. Once the dressing has been applied, the procedure is completed after another enoral bleeding check with dry wound conditions. The patient is ventilated via the tracheostoma and transferred to the in-house intensive care unit. Final consultation with the anesthesiologist.