After intubation via the supine tracheostoma and preparation by the anesthesia colleagues, a pharyngo/laryngoscopy was first performed. As described above, the tumor was found in the area of the left hypopharynx with extensive laryngeal destruction, extensive postcricoid growth towards the esophageal opening and extending directly in front of it. Growth towards the crania, also into the pre-epiglottic fatty tissue. Fixation of the hyoid on the right side, free conditions, with the tumor clearly reaching the midline, especially in the caudal transition. Inspection of the tracheostoma: the tracheostoma is reddened peristomally. Close inspection reveals a suspicious lesion in the area of the mucocutaneous anastomosis on the left side. This is a growth in the area of the tracheostoma. Therefore, skin incision to the apron flap with complete circumcision of the tracheostoma. Elevation of the apron flap with elevation of the platysma. Elevation of the platysma. First expose the sternocleidomastoid muscle on the right side, expose the omohyoid muscle of the submandibular gland and the digastric muscle. Dissection of the omohyoid muscle and initial attempt to visualize the laryngeal skeleton. This shows that the laryngeal skeleton on the right side has also been penetrated by tumor. Therefore, a muscular cuff was then left in place. Exposure and release of the hyoid on the right side. Ligation of the upper laryngeal bundle. Exposure and separation of the entire cervical vascular sheath. Dissection down to the prevertebral fascia. Mobilization of the larynx from the prevertebral fascia. This shows no infiltration by the tumor. Then, after complete loosening of the soft tissue on the right side, entry on the left side. This reveals infiltration of the sternocleidomastoid muscle and tumor infiltration of the right-sided cervical vascular sheath. Exposure of the submandibular gland and the digastric muscle. Exposure and later ligation of the facial vein. Release of the sternocleidomastoid muscle cranially and caudally in the area of origin. Exposure and later removal of the accessorius nerve. Removal of the neck preparation. Here complete. First expose the internal jugular vein cranially and caudally. Release of the cervical part of the tumor, including level V and partial revision of the cervical plexus. Despite the previous mobilization of the surrounding tissue, there is now evidence of widespread infiltration of the cervical vascular sheath. Therefore now careful opening. Exposure of the common carotid artery and cranial dissection. Exposure of the vagus nerve. Tumor growth is now clearly visible in the internal jugular vein. This is therefore removed cranially and caudally. In addition, there is a small growth on the vagus nerve and a circumscribed macroscopic change in the nerve. In addition, direct infiltration of the perivascular tissue of the common carotid artery with detachment of the perivascular tissue. The tumor can now be separated by initially bluntly detaching the vagus nerve. A marginal sample was taken in the area of the common carotid artery on the detached perivascular tissue, also in the marginal area of the vagus nerve. Clear cranial infiltration of the superior thyroid artery, which is separated. The further course of the external carotid artery is now free, so that after visualization and preservation of the hypoglossal nerve, no extension of the radicality is required here. In the frozen section diagnostics, the marginal samples in the area of the vagus nerve as well as in the area of the common carotid artery are now tumor positive. Therefore, after discussing the case and demonstrating the findings to <CLINICIAN_NAME>, long-distance resection of the vagus nerve and resection of the remaining perivascular connective tissue, but with preservation of the actual vessel wall. The vagus nerve is resected in an elongated fashion and sent for definitive histology. The post-resectate in the area of the common carotid artery is assessed as tumor-free. Exposure of the prevertebral fascia and complete detachment of the pharyngeal tube. Left-sided partial thyroidectomy also on the right side with adherence to the tumor DD scarred by the tracheotomy. Complete incision of the tracheostoma. Exposure of the trachea caudally, which is macroscopically and palpatorily free. Now turn to definitive tumor resection. To do this, enter above the hyoid on the right side, enter the right-sided vallecula, snare the epiglottis, widen the pharyngotomy. Resection along the right aryepiglottic fold. Due to the extensive laryngeal infiltration, the right-sided piriform sinus can only be partially released. Significant extensive postcricoid growth, here growing submucosally. Therefore, the entire postcricoid region must also be resected. As described above, the tumor can be seen in the area of the left piriform sinus as well as the left pharyngeal wall, in some cases extending to the midline. Excision of the tumor with a safety margin of approx. 1 cm, macroscopically in sano, macroscopically altered parts of the pharynx were removed. After removal, a caudal complete pharyngotomy with circular pharyngeal resection is performed; cranially, an approx. 2-5 cm wide pharyngeal strip can be preserved. Completely imaged marginal samples are now taken from the entire area of the detached mucosa as well as in the area of the base of the tongue and towards the esophagus. A marginal sample is also taken in the area of the separated trachea and in the area of the peristomally separated skin. These are diagnosed as completely tumor-free in the frozen section diagnostics, so that a local R0 situation can be assumed overall. Now complete the neck dissection of the right side. Due to the tumor resection, an extended radical neck dissection of the left side was performed en bloc on the specimen. Complete exposure of the digastric muscle on the right side. Exposure of the accessory nerve, exposure of the internal jugular vein, exposure and preservation of the facial vein, exposure and preservation of the hypoglossal nerve. Dissection of the internal jugular vein. Dissection of the accessorius triangle with careful protection of the nerve. Dissection of level V with careful protection of the cervical plexus branches. Finally, the defect is measured when the wound is dry. Due to the highly critical vascular supply and the radical resection, microvascular reconstruction is not performed. Elevation of a pedicled pectoralis major graft measuring up to 14 x 9 cm in total from the left. For this purpose, marking of the flap for complete pharyngeal reconstruction and marking of a temporary deltopectoral flap. This is lifted up to the 2nd angiosome, strictly subfascial preparation. Incision of the pectoralis major flap. Broad-based caudal dissection up to the rectus aponeurosis. Release of the pectoralis major muscle. Suture fixation of the muscle to the skin island. Cranial dissection strictly subfascial including the pectoralis major muscle. Exposure of the pectoralis minor muscle and the pedicle vessels. Subsequent resection of the muscle, leaving a cuff around the vascular pedicle. Cranial complete release of the pedicle vessel to allow maximum rotation and maximum freedom from tension. Creation of a wide cervical skin tunnel. Complete tension-free placement and insertion into the pharyngeal defect. A nasogastric tube was previously inserted into the separated esophagus. The surrounding skin is then carefully and extensively mobilized pectorally. Careful hemostasis. Subsequent strong and multi-layered wound closure after insertion of two 10-gauge Redon drains. Resection of protruding skin and subsequent repositioning of the temporarily elevated deltopectoral flap. Cervically, the graft is successively sutured to the separated esophagus under visualization. Strictly inverting suture at the mucosal level. Reanastomosis of the caudal part of the pharynx into the esophageal reconstruction to avoid subsequent stenosis, successive incorporation of the graft. Final good fit. Creation of a wide pharyngeal tube as well as intact and tight conditions on all sides with the flap in proper vitality. After final wound inspection, the tracheostoma is sutured and a 10-gauge Redon drainage tube is inserted and the wound is carefully closed in two layers. Re-intubation onto a 12 Rüsch cannula, which is suture-fixed, and completion of the procedure at this point. The patient received intraoperative intravenous antibiotics with Unacid 3 g, which should be continued for 24 hours postoperatively. Careful postoperative wound control in case of high risk of fistula due to complete pharyngectomy. Overall intraoperatively, a narrow R0 situation can be assumed in the area of the left common carotid artery, with overall extensive findings of a cT4a cN0 hypopharyngeal carcinoma on the left. In the case of regular wound conditions, an X-ray pre-swallow was performed on the 10th postoperative day.