After intubation and induction of anesthesia by the anesthesiology colleagues, a pharyngo-laryngoscopy is performed for re-evaluation. Here, the exophytic tumor process can already be seen in the area of the right oropharynx, starting at the border to the hypopharynx, in the area of the right pharyngeal side wall, the extensive exophytic tumor process moves over the right pharyngeal side wall into the piriform sinus, fills it completely, fixes the larynx here over the medial wall and also clearly moves postcricoidally here, the esophageal entrance is free, as is the posterior wall of the hypopharynx. In the region of the endolarynx, it is edematous and swollen on the right and regular on the left. Due to the absolute fixation, confirmation of the indication for laryngectomy. The patient is now repositioned and xylocaine with adrenaline is injected. Lifting of a broad-based apron flap. Start with the right side first. Extensive metastasis consisting of 2 large conglomerates, one in level II with palpatory clear infiltration of the sternocleidomastoid muscle and one extending caudally to the supraclavicular region, mainly in level IV and V to Vb. The sternocleidomastoid muscle is visualized for orientation. Subsequently, the muscle is placed on the mastoid and caudally. Exposure of the omohyoid muscle, which is also infiltrated in level IV, cranial exposure of the submandibular gland, exposure of the facial vein, which is later ligated, exposure of the digastric muscle, which can just be bluntly detached from the metastasis block. No infiltration here. Cranial exposure of the internal jugular vein, this is already very thin here, the accessorius nerve is no longer exposed here. Exposure and preservation of the carotid artery with hypoglossal nerve, exposure and preservation of the vagus nerve, cranial removal of the internal jugular vein, caudal dissection with subtotal resection of the cervical plexus. Skeletonization of the carotid bulb and the common carotid artery. After dissection, this can be pushed away from the metastatic block completely including the adventitia, partly bluntly, no signs of infiltration here. Caudally just above the mouth of the subclavian vein, separation of the internal jugular vein with overall extensive infiltration and obliteration, caudally good separation from the brachial plexus, no signs of infiltration here either, so that overall the complete metastatic block can be extirpated in toto and in sano. The vagus nerve was also preserved along the entire route. Residues of level Ia and level VI are extirpated, followed by visualization and release of the hyoid on the right side. Release of the thyroid cartilage in case of tumor growth, but certainly no tumor breakthrough. Covering of the soft tissues of the neck everywhere. However, the paralaryngeal muscles on the right side were left intact. Mobilization of the larynx only caudally. Detachment of the thyroid gland and preservation of the superior thyroid artery. Exposure and exposure of cricoid cartilage and trachea. On the left side now classic dissection and skeletonization of the larynx. Detachment of the paralaryngeal and infrahyoid muscles. Exposure of the thyroid horn, sharp release of the piriform sinus. Now enter cranial to the hyoid due to the extent of the tumor on the left. Paramedian successive extension of the pharyngotomy via the left-sided vallecula, sparing and mucosa-sparing resection in the area of the aryepiglottic fold on the left up to the postcricoid while preserving and releasing the piriform sinus. On the right side, the tumor is incised in situ with a safety margin of approx. 1.5 cm, taking the pharyngeal musculature with it and thus also safely in sano in depth. Resection up to the postcricoid, here about half of the tumor is affected. Healthy conditions on all sides towards the esophageal entrance. Finally, removal of the specimen below the cricoid cartilage. Inspection of the tumor, practically no extension subglottically and wide in sano resection here, the tumor is resected in sano on all sides on the specimen, so that the marginal sample is taken on the specimen. Only in the area of the postcricoid region is there a somewhat narrower distance after removal of the tumor block, which is why complete imaging of the mucosa and margin samples is performed in situ. In the frozen section diagnostics, all marginal samples are free of tumor and dysplasia, so that an R0 situation can be assumed. The neck dissection of the left side is now performed. Here, metastasis at the transition from level II to Va behind the internal jugular vein. Macroscopic visualization of the omohyoid muscle and digastric muscle. Release of the submandibular gland, visualization of the omohyoid muscle, digastric muscle. Release of the submandibular gland, exposure of the sternocleidomastoid muscle, free preparation of the internal jugular vein while preserving the facial vein. Exposure and preservation of the accessorius nerve, hypoglossal nerve and cervical artery. Exposure and preservation of the superior thyroid artery. The metastasis described above can be removed in sano without any signs of surrounding infiltration. Further borderline enlarged lymph nodes on the internal jugular vein are resected en bloc with the neck dissection which extends to level Va. Final palpation also on both sides in the nuchal and supraclavicular direction, no further abnormalities, so that after wound irrigation, the Provox voice prosthesis is initially placed here with a regular esophageal entrance, good mucosal conditions and a regular trachea. The trachea is adjusted by creating a dorsal elevation. Easy insertion of a size 8 Provox prosthesis at the most cranial point possible. Particularly in the area of the caudal pharyngeal tube and the esophageal entrance, the mucosa is wide, so that after a demonstration of the findings at <CLINICIAN_NAME> and <CLINICIAN_NAME> a primary suture of the mucosa is performed in several layers, especially including the base of the tongue in the case of a larger defect on the right side due to the extent of the tumor. Finally, wide conditions and an intact pharyngeal tube on all sides. Due to the skeletonized common carotid artery and the larger pharyngeal defect, the right thyroid lobe is now rotated to reline the pharyngeal suture. Release of the right thyroid lobe with removal of the inferior pole. The thyroid gland is now stitched onto the stalk of the superior thyroid artery and the accompanying veins, particularly on the cranial part of the pharyngeal suture. Good positioning. Subsequent final wound irrigation and, if the wound is dry, insertion of a 10-gauge Redon drain. Careful two-layer wound closure and insertion of the tracheostoma. Subsequent problem-free reintubation to a size 10 low cuff cannula. Conclusion: Intraoperative R0 resected cT4a cN2c cM0 G3 hypopharyngeal carcinoma on the right. Postoperatively, forced adjuvant therapy is certainly required due to the advanced metastasis. An X-ray pelvis was performed on the 10th postoperative day. If there are signs of a pharnygocutaneous fistula, please report this to the surgeon at an early stage.