Initially after induction and preparation by the anesthesia colleagues. Performing a pharyngo-laryngoscopy to determine the extent of the tumor again. Entry with the Kleinsasser tube under dental protection. This reveals pronounced edema of the left aryepiglottic fold with marked edema of the left arytenoid. The endolarynx is barely adjustable. There is an exophytic, exulcerated tumor in the area of the left piriform sinus with pronounced induration and palpatory high-grade v.a. continuous growth into the soft tissues of the neck, which corresponds to the CT imaging. The free entrance to the esophagus and the piriform sinus on the right side are tumor-free, as is the posterior pharyngeal wall. The exophytic area just does not reach this. Therefore, repositioning for resection from the outside. First elevation of an apron flap incision to just above the tracheostoma. Here, with the tracheostoma clearly torn out preoperatively and a very short neck, the incision is made just above the tracheostoma. Cranial preparation of the apron flap and suture fixation. Start with neck dissection of the left side. Palpation reveals an extensive, extremely hard and barely mobile neck metastasis. Initially caudal and cranial exposure of the sternocleidomastoid muscle. First visualization, later removal of the external jugular vein and the auricularis magnus nerve in case of safe infiltration by the metastasis Removal of the sternocleidomastoid muscle cranially and caudally. Exposure of the omohyoid muscle is not possible with complete infiltration. Visualization of the submandibular gland. Infiltration can also be seen later on. The same applies to the digastric muscle. This is visualized posteriorly and anteriorly and severed. First release of the mass, which extends caudally to level Vb. Careful release and preservation of the brachial plexus, which is not infiltrated. Release and preserve the cervical transverse artery and vein. Strict control of lymphatic leakage. Protection of the subclavian vein. Partial resection of the cervical plexus in case of infiltration, accessorius nerve can no longer be visualized in case of infiltration. Partial thyroidectomy in case of questionable infiltration of the upper pole, here clear adherence of the tumor. In the case of extensive destruction of the larynx and suspected continuous growth, no further visualization of the laryngeal skeleton. Cranial exposure of the tumor with resection of the submandibular gland and description of the digastric muscle. Caudal exposure of the long infiltrated internal jugular vein, which is placed caudally. Difficult visualization of the arteria carotis communis and the vagus nerve, which are displaced very far caudally and to the depth. These are initially free caudally. Exposure of the prevertebral fascia; a free layer can be exposed here. Now successively expose the largely walled-in common carotid artery, initially walled in far to the cranial in the area of the internal carotid artery, the vagus nerve must be removed if infiltration is safe. Consultation and demonstration of findings at <CLINICIAN_NAME>. The metastasis is now opened selectively to better expose the internal carotid artery. The internal carotid artery can be preserved by dissecting all vascular layers. No reliable evidence of infiltration. The external carotid artery is completely walled in close to the outlet without the possibility of free dissection, therefore the artery is removed after puncture and ligation. Resection of the hypoglossal nerve, careful dissection of a metastatic cone in the direction of the base of the skull in the case of long infiltration, extremely difficult dissection conditions and clear adherence. The extension ends here in a rough tissue alteration. A representative marginal sample is taken here later. Finally, the metastasis can be removed from the neck area. Only the prevertebral fascia, parts of the paravertebral musculature and the common carotid artery with the internal carotid artery and remnants of the cervical plexus remain. Now free preparation of the larynx on the right side, exposure of the hyoid, which is also infiltrated on the left side. Release of the piriform sinus, entering the vallecula above the hyoid. Looping of the epiglottis. After opening the pharynx wide in the pharyngotomy along the aryepiglottic fold on the right, successive gaining of an overview of the tumorous process. Significant aryoedema. Therefore postcricoid removal of approx. 1 cm of postcricoid mucosa. Resection of the tumor with a safety margin of approx. 1-1.5 cm. Release of the cricoid cartilage. Mobilization up to the trachea after previously performed right-sided thyroidectomy. Exposure of the free esophageal entrance and resection of the tumor in toto with the attached cervical metastasis, after removal below the cricoid cartilage while taking the first tracheal clasp subglottically, certainly no tumor growth, but with previous tracheotomy removal of a marginal sample in the area of the posterior tracheal wall in scarred conditions. In addition, completely covering mucosal margin samples. The frozen section diagnosis now shows a positive marginal sample in the area of the posterior tracheal wall and residual infiltrates in the area of the skull base with tumor-free marginal samples in the area of the primaries. Therefore, obtaining a post-resectate in the area of the skull base. Extensive release of any soft tissue area of the skull base while sparing the internal carotid artery. This is removed as a post-resectate for definitive histology. Final marginal sample in the area of soft tissue remnants, these are diagnosed as tumor-free in the frozen section, also in the area of the posterior wall of the trachea Removal of the posterior wall of the trachea and the surrounding soft tissue. A resection is also made here. A representative final marginal sample is then taken, which is also diagnosed as tumor-free. Due to the now clearly resected posterior tracheal wall, it is not necessary to insert a provox prosthesis at this point. Now to the neck dissection of the right side. Exposure of the sternocleidomastoid muscle. Exposure and preservation of the external jugular vein and the auricularis magnus nerve. Exposure of the omohyoid muscle. This has already been dissected from the laryngeal skeleton. Exposure of the submandibular gland and the digasatric muscle. Exposure of a very strong facial venous branch, which appears to flow into the jugularis anterior current area; this is ligated and deposited in the transverse course. Exposure and dissection of the internal jugular vein. Release of the anterior neck preparation with partial ligation of the superior thyroid artery. Preservation of the hypoglossal nerve. Exposure of the accessorius nerve. Clearing of the accessorius triangle. In the area of the cranial muscle part of the sternocleidomastoid muscle, a coarse, macroscopically altered area can be seen here, partly scarred, but partly also appearing tumorously altered. Likewise in the area of the middle of the muscle, also scarred, dd tumorous area. Therefore resection of both areas. Subsequent complete excision of the accessorius triangle and level V, sparing the cervical plexus branches. Finally, wound inspection and, if the wound is dry, evaluation of the pharyngeal defect. An intact, strong residual pharyngeal tube is found, but with a clear tendency towards stenosis, particularly cranially, and in the case of primary occlusion, the common carotid artery or internal carotid artery is also unprotected over a long distance. Therefore, after initial preparation for ALT removal on the left, demonstration of findings and case discussion with <CLINICIAN_NAME>. Due to the co-mobility with known vascular disease, treatment using a pedicled pectoralis major graft is preferred to defect coverage using a microvascular graft. A defect of approx. 8 x 7 cm is measured in the area of the pharynx. If secondary reconstruction is required, a temporary deltopectoral flap is lifted first. Signs of the pectoralis major graft. Elevation of the deltopectoral flap up to the second angiosome. Separation of skin and subcutaneous tissue. Exposure of the deltoid muscle. Strictly subfascial dissection. Protection of the Mohrenheim fossa and the cephalic vein. After medial preparation and moistening of the transient graft, resection of the pectoralis major graft. After cutting around the skin island, lift a broad muscle head laterally to cover the soft tissue in the area of the carotid artery. Release of the pectoralis muscle, strictly suprafascial preparation, exposure of the pectoralis minor. Cranial dissection with careful protection of the vascular pedicle after reliable identification of the latter. Leave a muscle cup to protect the vascular pedicle. Dissection of the vascular pedicle up to the Mohrenheim fossa, then complete resection of the attached pectoralis major muscle. The skin island can then be inserted into the pharyngeal defect completely tension-free. After insertion, a very wide skin tunnel without any tendency to tension can be seen. Therefore tunneling through the flap pedicle. Suture the skin island into the pharyngeal defect with 3.0 mucosal sutures. This works well and fits perfectly. Then cover the internal carotid artery with the attached muscle graft. This allows the artery to be covered with muscle along its entire length. After inspection of all wound cavities, two 10-gauge Redon drainage tubes are inserted pectorally and one 10-gauge Redon drainage tube is inserted on the left side; drainage on the right side must be omitted in the event of repeated loss of suction due to the tracheostoma arrangement. Subsequent careful two-layer wound closure. The tracheostoma should be sutured beforehand. Adaptation of the anterior skin. Due to the tension already present here, a tracheostoma resection is not performed anteriorly. Healthy granulation tissue on all sides and already existing wound healing disorder, therefore no further measures here. The tracheostoma ends caudally over the apron flap. The procedure is then completed without any indication of complications. The patient received intraoperative antibiotics with Unacid 3 g. Conclusion: cT4a hypopharyngeal carcinoma on the left with extremely aggressive and per continuitatem growing neck metastasis on the left, in this case an extended, radical neck dissection was performed, taking all neck structures with it except for the common carotid artery. Intraoperatively, the situation was clearly R0 with regard to the primary tumor. Due to the aggressive metastasis, exhaustion of adjuvant therapy options is certainly necessary. Postoperatively, due to the neck situation on the left, rapid indication for surgery if a fistula is detected, otherwise it is recommended to carry out an X-ray pelvis on the 10th postoperative day. After completion of wound healing, a secondary Provox treatment appears conceivable in the interval.