Transferring the patient to the operating theater and positioning the patient. Introductory consultation with the anesthesia department and team time-out. Problem-free intubation. First attempt at PEG placement. There is no clear diaphanoscopy here, so the PEG is not inserted. Marking of the landmarks and skin incision, dissection through the subcutaneous fatty tissue. Exposure of the prelaryngeal musculature, strict dissection along the alba line into the deep and lateral spread of the prelaryngeal musculature. Exposure of the thyroid gland. Coagulation below the cricoid cartilage and transection of the thyroid gland using 2 Pean clamps and a bypass as well as bipolar coagulation. Exposure of the anterior wall of the trachea and exposing it. Insertion between the 2nd and 3rd tracheal cartilage in the sense of a visor tracheotomy. The brachiocephalic trunk can be seen pulsating in depth. However, a layer of tissue and fat can still be identified over the brachiocephalic trunk. Incision of the tracheostoma in the usual manner. Now sterile abjoration and covering. Exposure of the tumor in the hypopharyngeal region with the spreading laryngoscope. The tumor is stalked on the medial pharyngeal wall and on the anterior piriform sinus wall and extends laterally to the arytenoid cartilage. The posterior pharyngeal wall and also the lateral pharyngeal walls are free. The tumor is now successively removed using a CO2 laser with a safety margin of at least 1 cm in all directions. The arytenoid cartilage remains and is covered with a layer of mucous membrane. No pharyngeal fatty tissue is visible. After removal of the tumor and hemostasis using bipolar coagulation, suture marking of the specimen and submission for frozen section, this shows an R0 resection, for this reason repositioning for neck dissection on both sides, starting on the right side. Marking of the landmarks. Skin incision and dissection through the subcutaneous fatty tissue. Exposure of the anterior border of the sternocleidomastoid muscle and exposure of the accessorius nerve. Dissection along the omohyoid muscle in a cranial direction and exposure of the submandibular gland. Exposure of the posterior venter of the digasatric muscle and preparation in the direction of level IIb. Successive free dissection of the venter posterior digastric muscle and caudal exposure of the neck preparation. Free dissection of the internal jugular vein and successive dissection of the lateral neck preparation. N. accessorius and the plexus ........................................ can be spared. Identification of the vagus nerve, which can also be spared. Dissection of the jugulofacial angle and visualization of the hypoglossal nerve, which can also be spared. Now successive removal of the medial neck preparation. All in all, inconspicuous neck side with removal of the lymph nodes from level II to V. No indication of increased bleeding. Bleeding. Application of a redon drainage and two-layer wound closure. Transfer to the left side. Here too, skin incision and dissection through the subcutaneous fatty tissue. Exposure of the anterior border of the sternocleidomastoid muscle. This shows a large metastasis of 6.5 cm in level IIb which extends under the posterior digastric muscle and up to the mastoid. For this reason, first dissect the omohyoid muscle and expose the submandibular gland. Pull up the submandibular gland and expose the posterior venter of the digastric muscle. Dissection posteriorly in the direction of level IIb. Exposure of the internal jugular vein in the caudal area and free dissection of this. Likewise exposure of the facial vein and free dissection of this. Now successive detachment of the metastasis from level IIb and the internal jugular vein. This is achieved successively using bipolar coagulation and scissors. The metastasis can be sharply detached from the posterior digastric vein. The vein, the accessorius nerve and the sternocleidomastoid muscle can be preserved and are not infiltrated. After removal of the large metastasis, successive evacuation of the lateral neck preparation while sparing the brachial plexus. Identification of the hypoglossal nerve in the jugulo-facial angle and protection of the vagus nerve, successive dissection of the medial neck preparation. Hemostasis. There is no evidence of increased bleeding. Irrigation of the situs. Neck dissection from level II to level V was also performed here. If conditions were normal, insertion of a Redon drain and two-layer wound closure. Re-intubation blocked on an 8-gauge Rüsch cannula. There is no evidence of increased bleeding on all sides. Final consultation with the anesthesia department. The PEG insertion should be planned with the colleagues at <CLINICIAN_NAME>.