Pharyngo-oesophageal perforation is a rare and serious complication that can occur during transoesophageal echocardiography (TOE), associated with mortality up to 28%. Managing this iatrogenic trauma traditionally necessitates complex open surgery. We report a case of oesophageal perforation following TOE successfully treated with open neck exploration and oesophageal repair. An 84-year-old female underwent a TOE as part of a pre-operative work-up for multi-valvular replacement under cardiothoracic surgery. Difficulty was encountered initially passing the probe through cricopharyngeus. A smaller probe was used, and on insertion, a visible oesophageal perforation was noted. ENT was consulted and the patient was transferred to the operating room immediately while intubated. An open neck exploration was performed, which identified a 2cm perforation at the right pyriform. A nasogastric tube was placed under vision, and the defect was repaired (see intra-operative images). Post-operatively she was placed on broad spectrum IV antibiotics and fasted. Serial contrast swallows were performed at 1 and 2-weeks post-operatively to assess for leak. A diet was slowly reintroduced with guidance from dietetics, and the patient made a full recovery. This case underscores the importance of vigilance in recognising iatrogenic trauma during TOE and emphasises the critical role of interdisciplinary collaboration in achieving favourable patient outcomes. Open neck exploration is an effective surgical method to manage these injuries. Lessons learned from this contribute to refining protocols for TOE procedures, enhancing patient safety, and guiding clinical decision-making in similar high-risk scenarios.