Pharyngoscopy and laryngoscopy again: The hypopharyngeal tumor is seen on the right, which extends to just before the base of the tongue and grows into the epiglottis and also grows laterally further caudal to the larynx in the area of the aryepiglottic fold. Tip of the piriform sinus free. Overall, surgery is now confirmed as an indication. The patient is now repositioned. Skin disinfection. Sterile draping of all relevant surgical areas. Start of the operation with apron flap, left neck revision and tracheostoma placement. Marking of the apron flap in the area of the former neck sutures. Now incision of the skin and subcutaneous tissue. Identification of the platysma and transection of the platysma. <CLINICIAN_NAME> on the left side, <CLINICIAN_NAME> on the right side: Identification of the anterior edge of the sternocleidomastoid muscle and careful dissection along the muscle in depth to protect the cervical vascular nerve sheath. Overall very scarred conditions after radiotherapy. Identification of the accessorius nerve on both sides. Identification of the submandibular gland and the posterior venter of the digastric muscle. Identification of the jugular vein, the common carotid artery and the vagus nerve. Identification of the omohyoid muscle and dissection of the muscle. After palpatory identification of the hyoid bone, the hyoid bone is detached from the base of the tongue at the cranial end. Identification of the hypoglossal nerve on both sides, which can be spared. Now detach the prelaryngeal musculature from the laryngeal skeleton. Dissect the laryngeal skeleton while sparing the constrictor pharyngeus inferior muscle and lateralizing the cervical vascular nerve sheath. Now detach the thyroid gland from the left and right. Two suspicious lymph nodes are removed on the left side in region II, which were previously identified by ultrasound. No suspicious masses were found during the other dissection. The laryngeal opening and tumor resection is dictated by <CLINICIAN_NAME>. Tracheotomy was also performed. Wound closure by means of implanted cartilage is seen in patients who have already undergone a tracheotomy. The cartilage cover can be released and the trachea opened. At the end of the operation, two-layer wound closure using cutaneous and subcutaneous sutures. Placement of 2 Redon drains and completion of the surgical procedure without complications. PEG insertion: After abdominal surgery, a good diaphanoscopy was performed in an attempt to insert a PEG using the thread pull-through method, but a mass was palpable above the diaphanoscopy and a dark shadow was visible. Gastroscopically, the stomach appears anatomically altered and small. For these two reasons, a PEG is not inserted. Should a fistula form, a PEG should be inserted in the surgical department or in Medical Clinic 1. Subsequent laryngectomy and partial pharyngectomy: First dissection of the infrahyoid muscles from the hyoid bone and knocking them down caudally. Detachment of the suprahyoid muscles from the hyoid bone. Exposure of the .........superior on the left. Dissection of the pharyngeal tube. Dissect the thyroid gland caudolaterally on both sides. Subsequent exposure of the epiglottis from the left. Entering the pharyngeal space. It can be seen that the tumor on the left has grown almost to the base of the tongue. Partial resection of the base of the tongue from the middle to the right is therefore performed. The tumor is resected macroscopically with a safety margin of 1.5 cm on all sides. The entire pharyngeal wall on the left and caudal parts of the base of the tongue are resected. Caudally, the mucosa in the postcricoid area is removed. On the left side, the hypopharynx can be preserved as far as possible. Finally, the larynx and parts of the pharynx are removed. Due to the expansion at the base of the tongue, an extensive marginal sample is taken from the entire base of the tongue. Both the main specimen and the marginal specimen in the base of the tongue are sent in marked with sutures for frozen sectioning. Here, marginal samples of the base of the tongue are free, but there are still infiltrates at the transition from the base of the tongue or epiglottis to the lateral pharyngeal wall on the right. Therefore, another extensive resection of the mucosa on the right and removal of a marginal sample from the point where the base of the tongue was free down to almost the transition to the postcricoid area. Here the marginal sample was then subsequently free, so now R0 resection. Ultimately, the resection extends cranially to the tonsillar lobe to just under the palatal arch. Flap coverage is therefore necessary to enable tension-free closure, especially after radiation. Due to the overall situation and the good conditions in the area of the chest wall, the decision was made to elevate a pectoralis major flap to cover the defect, from the right side. Then lift and suture the pectoralis major flap. Lifting the pectoralis major flap: Locate the lateral end of the pectoralis major in the line connecting the axilla and the lower edge of the sternum. Dissection of a deltopectoral flap and undermining of the skin until a complete hand fits through. Now locate the pedicle. Measure the length of the flap with a compress and mark the skin area. Now cut around the skin area and dissect through the subcutaneous fatty tissue. The pectoralis major muscle is now separated from the chest along the lateral muscle edge to create the myofasciocutaneous flap. Suture with Vicryl 4-0 to prevent shearing. Successive further elevation of the flap with dissection along and through the pectoralis major muscle. The pedicle is visible the entire time and can be spared without any problems. Once the length of the flap is sufficient, fold it over and suture it in inverted form onto the remaining pharyngeal tube. Suture the muscles to the prevertebral fascia on both sides. A Provox is not inserted in the case of post-radiation. Insertion of 2 Redon drains in the chest as well as one Redon drain cervical right and one Redon drain cervical left. Two-layer wound closure of both the breast defect and the cervical defect on both sides. Careful suturing of the tracheostoma. Suturing of a 10-gauge ruffled cannula and suturing of this. Completion of the operation. The patient should continue to receive antibiotics with Unacid 3 g. An X-ray gruel swallow is possible after 14 days at the earliest. Subsequent irrigation of the wound area. Hemostasis and wound closure in layers, with insertion of two Redon drains into the side of the neck and epithelialization of the tracheostoma. The procedure was completed without complications. PEG placement was attempted intraoperatively, but was not possible due to insufficient diaphanoscopy. Therefore, please register patients for PEG placement in the surgery department or in Medical Clinic 1 at intervals. Until then, nutrition via the inserted gastric tube. Total second carcinoma of the hypopharynx R0-resected with partial pharyngectomy and laryngectomy. A myotomy was created on the left side to facilitate passage later. On the advice of the phoniatrists, a Provox prosthesis was not inserted. This should also be inserted at intervals. The patient is admitted to the intensive care unit for postoperative monitoring. Please continue antibiotics for one week. X-ray pelvic examination after 14 days, then, if necessary, a diet. Presentation at the interdisciplinary tumor conference to determine further treatment. If nodes on the left are positive, radiochemotherapy will probably be necessary.