After positioning the patient, first enter with the small irrigation tube while protecting the dental ridge. Inconspicuous oral cavity. Careful inspection of the oropharynx, especially the tonsil regions. Careful palpation and inspection. There are absolutely symmetrical, slightly bumpy and cryptic tonsils on both sides, absolutely idem in lateral comparison. Therefore, no further measures are taken here. Adjustment of the endolarynx. This is inconspicuous and free. The same applies to the left hypopharynx. In the area of the right piriform sinus, starting in the entrance area, an exophytic, coarse mass is now visible, relatively well demarcated. This extends from the piriform sinus over the posterior and lateral wall to just before the tip and can be easily moved by palpation, but has an infiltration depth or tumor thickness of just under 1 cm. Due to the good displaceability and visualization, the decision was made to perform a primary laser resection. Resection of the tumor with the CO2 laser 2.0 W, microscopically controlled. Complete removal. Good controllability in the depth range. Slightly more difficult resection conditions in the direction of the tip of the piriform sinus. Otherwise complete in-sano removal with particularly good control in the direction of deep growth. The entire tumor in the area of the mucosa is now covered with marginal samples. In addition, samples are taken from the basal tissue and the muscles located here. All samples are diagnosed as tumor- and dysplasia-free. An R0 situation can therefore be assumed here. Careful hemostasis. Due to the resection area with contact to the lateral hypopharyngeal side wall, a tracheostomy is later indicated. Performing flexible esophagogastroscopy for the planned PEG insertion: Easy pre-scanning into the stomach. Despite optimized positioning, there is no diaphanoscopy. Therefore, a PEG insertion must be dispensed with at this point. A nasogastric feeding tube is inserted under laryngoscopic control. Repositioning for neck dissection. Injection of xylocaine with added adrenaline. Start on the right side. Clearly palpable, coarse mass of a good 3 cm in size at level II. Dissection of skin and subcutaneous tissue. Exposure of the sternocleidomastoid muscle. Exposure and preservation of the auricularis magnus nerve. The external jugular vein is removed. Exposure of the omohyoid muscle, exposure of the submandibular gland and the digastric muscle. Removal of the anterior neck preparation, carefully preserving the facial vein, the cervical vein, the hypoglossal nerve and the superior thyroid artery. Free preparation of the internal jugular vein. The highly suspicious mass described above can be seen in the area of the jugulofacial angle. After careful dissection, the metastasis can be detached from the internal jugular vein, the accessorius nerve and the sternocleidomastoid muscle. Release of the accessorius triangle and clearing of level V with careful protection of the cervical plexus branches. A clearly suspicious mass is also visible in level III, lateral to the internal jugular vein. Dissection up to the transition to level V b. Final wound inspection. In dry wound conditions, after wound irrigation, insertion of a 10-gauge Redon drain and careful two-layer wound closure. Repositioning to the opposite side. In principle exactly the same procedure here. After exposing the surrounding musculature, evacuation of the anterior neck preparation with careful protection of the cervical artery, the superior thyroid artery, the hypoglossal nerve and the facial vein. Here, too, a mass measuring a good 2.5 cm was found in the area of the jugulofacial angle. Macroscopically clearly suspicious. Therefore, complete evacuation of the accessorius triangle with careful protection of the nerve. Clearing of level V a with careful protection of the cervical plexus branches, protection and exposure of the common carotid artery and vagus nerve. Final inspection. Careful hemostasis. Wound irrigation, insertion of a 10-gauge Redon drainage, two-layer wound closure. Finally, a protective tracheotomy is performed: for this purpose, a skin incision is made approx. 1 cm below the cricoid cartilage. Cut through the skin and subcutaneous tissue. Expose and cut through the infrahyoid muscles. Exposure of the cricoid cartilage, exposure of the anterior surface of the trachea. Creation of a broad-based pedicled Björ flap and subsequent insertion of the tracheostoma in the usual manner. Easy transfer to a size 8 low-cuff cannula. Final enoral inspection of the resection area. The procedure was completed with dry wound conditions and no indication of complications. Conclusion: Intraoperative R0-resected cT2 hypopharyngeal carcinoma on the right. Intraoperative high-grade cN2c neck status. Please feed via the inserted nasogastric feeding tube for about 4-5 days. After that, gradual diet build-up possible. Due to the adjuvant therapy that will certainly be required, a second PEG should be inserted. However, this should not be done before the 10th postoperative day. If swallowing function and enoral healing are normal, decannulation should be possible during the inpatient course.