First, pharyngoscopy and laryngoscopy again: The described, deeply exulcerating tumor in the hypopharynx on the left is visible, which grows up to the arytenoid fold on the left and involves the hypopharyngeal side wall and extends under the tonsillar lobe in the hypopharynx. On the other side, the flat, papillomatous tumor in the arytenoid region on the right is visible. The above-mentioned indication for surgery was confirmed. First skin disinfection. Injection of a total of 15 ml xylocaine 1% with adrenaline into both sides of the neck. Sterile draping. Radical neck dissection on the left follows: Skin incision in the typical manner along the sternocleidomastoid muscle. Extension at a 90° angle in the direction of the submandibular lobe. Subsequent exposure of the sternocleidomastoid muscle, exposure of the omohyoid muscle, exposure of the digastric muscle. Exposure of the cervical vascular sheath, internal jugular artery, internal and external carotid artery, vagus nerve, boundary cord of the accessorius nerve and hypoglossal nerve. There is a large conglomerate of lymph nodes extending from caudal to cranial lateral to the cervical vascular sheath. It infiltrates the sternocleidomastoid muscle, the internal jugular vein and branches of the cervical plexus in the upper area. The internal jugular vein is dissected cranially and caudally from the tumor, is not affected here and is ligated twice. A caudal outlet remains in the direction of the thyroid gland. Cranial also double ligation. The internal carotid artery can be completely dissected. Caudal exposure of the thoracic duct or a large lymphatic vessel in the venous angle, which is ligated twice. The conglomerate is then removed laterally from the cervical vascular sheath, including the sternocleidomastoid muscle, the internal jugular vein, the accessorius nerve and resection of the upper cervical plexus branches. Parts of the prevertebral, paravertebral musculature must also be removed. Here in the area of the strongest adherence of the lymph node preparation, marginal samples are taken, also from the upper end of the separated internal jugular vein. Both marginal samples are sent for frozen section. No tumor infiltrates here in the frozen section. All soft tissues, including parts of the trapezius muscle, were resected. Subsequent clearing of levels Ib and Ia, including the submandibular gland. Exposure and preservation of the hypoglossal nerve and lingual nerve. Also preservation of the facial artery. Subsequent tumor resection: First exposure of the hyoid bone from the lateral or superior cornu. Insertion between hyoid bone and superior cornu. Exposure of the tumor. The tumor is incised on all sides with a safety margin of 1 to 1.5 cm. The entire lateral hypopharyngeal side wall and the posterior hypopharyngeal wall are removed; resection extends up to the base of the tongue and under the tonsillar lobe. Resection extends from the vallecula, next to the epiglottis downwards, including the aryepiglottic fold and the piriform sinus to the tip of the piriformis. The tumor is macroscopically removed from the healthy tissue and is thread-marked for frozen section. To be on the safe side, a lateral specimen is taken adjacent to the epiglottis, including parts of the base of the tongue and the cranial resection margin. In the frozen section, infiltrates in the lateral and cranial direction in the sense of a microinvasive carcinoma or carcinoma in situ infiltrates. Therefore, resection laterally and cranially and removal of a marginal sample from the lateral, divided into lateral and caudal, including the remains of the arytenoid fold or the mucosa towards the postcricoid region and including further lateral parts of the epiglottis and vallecula region. Also resection again cranially and removal of a marginal sample, which extends from the base of the tongue over the lateral pharyngeal wall to the cranial border in the oropharynx. The frozen section is now free laterally, but there are still in situ infiltrates cranially. Therefore, another extensive resection of a wide mucosal strip is performed cranially. The marginal samples are taken transorally by inserting a Mc Ivor spatula. For this purpose, a cranial mucosal strip of the residual mucosa, which is already located behind the uvula, is removed as well as the residual tonsil and a strip from the side wall of the pharynx. All these marginal samples are sent to the frozen section again as a cranial marginal sample. No more tumor infiltrates here. Therefore, an R0 resection can now be assumed. Subsequently, resection of the 2nd carcinoma in the area of the arytenoid hump on the right. This is a flat, papillomatous carcinoma. This is macroscopically incised on all sides with a safety margin of several millimeters in healthy tissue and sent for frozen section examination with a suture marker. Here in the dorsal and lateral area still carcinoma in situ. Therefore, resection of the dorsal and lateral areas and removal of representative marginal samples. These are now tumor-free. Thus an R0 situation here too. However, extensive hypopharyngeal carcinoma with in situ can be assumed in the case of suspected field carcinoma and a second carcinoma in the case of suspected polycentric carcinoma. The residual mucosa in the postcricoid area is now readapted cranially as far as possible in order to achieve improved sensitivity and mucosal coverage using 5/0 Vicryl sutures. During the tumor resection, a plastic tracheostoma was created by reopening in the case of a post-dilatation tracheostomy. The old scar was reopened in the cranial region, the trachea was exposed and epithelialized in the 2nd and 3rd intercartilage space in a typical manner using a wide pedicle Björk flap. Insertion of a laryngectomy tube. Following the tumor resection Neck dissection on the right: Level II to IV as well as larger parts of V. Multiple suspicious nodes are also removed here. The internal jugular vein, internal/external carotid artery, vagus nerve, accessorius nerve, hypoglossal nerve, border cord and the branches of the cervical plexus were preserved here, as was the superior thyroid artery. A femoral flap was then removed from the left side to cover the defect. After measuring the defect, which required a size of 12 x 8 cm, a flap size of 17 x 8 cm was measured, as the flap is to be lifted with a skin island as a monitor. Several perforators can be displayed. The flap is outlined around the perforators. First cut medially through the skin and subcutis to the fascia. Dissect below the fascia up to the intermuscular septum. Widen the incision cranially and expose the vascular pedicle of the descending ramus. Also expose the perforators, which all extend through the musculature. The vascular pedicle is exposed up to the exit from the profunda femoris artery. Here the artery reaches a good thickness. Equally good venous confluence can be visualized. The flap is then incised laterally. After cutting through the fascia, a larger part of the vastus lateralis muscle is resected with the intermuscular course of the perforators, particularly in the caudal region. Outgoing branches are bipolarly coagulated or treated with a clip. The vascular pedicle is placed directly on the profunda femoris artery. Good reflux from the superficial circumflex iliac artery, which must be removed due to the anatomical conditions at the flap stalk. The associated veins are also removed. The vascular pedicle is then removed. All arteries and veins are supplied using 4/0 Prolene puncture ligatures. Flap is rinsed with heparin and preserved. The thigh wound is closed in layers after careful hemostasis and insertion of a Redon drain. The flap is then inserted into the defect and sutured into the defect without tension after the sutures have been placed. An approx. 5 cm wide, de-epithelialized bridge to a skin monitor was created in the caudal area. The defect was closed completely and with minimal tension. The vessels are connected after trimming and conditioning of the vessels. An end-to-end anastomosis is made between the superior thyroid artery, which was preserved during the radical neck dissection, and the descending ramus with 8/0 ethilon sutures. This is followed by the anastomosis between the main venous drainage vessel and the external jugular vein, which was also preserved during the neck dissection. A size 3/5 coupler is used for this. After arterial anastomosis good venous return via the vein, after venous anastomosis good venous return. Flap vital. This is followed by careful hemostasis. Overall, hemostasis is sometimes very difficult during the operation as there is constant and diffuse bleeding from the various tissue sections due to coagulation disorders. Skin closure of the neck wound on the right is achieved without any problems by inserting a Redon drain. Skin closure of the wound on the left with insertion of the skin monitor. However, due to the increased tissue tension in the middle area, a small portion of the skin remains unsutured to prevent compression of the flap. A flap was inserted on the left. The laryngectomy tube is replaced by a tracheostomy tube with a core, which is fixed with sutures. The procedure is completed without complications. Patient goes to the intensive care unit for monitoring. Overall, due to continuous bleeding with impaired coagulation, need for blood reserves and coagulation factors. At the end of the operation, the jugular vein was easy to check with the Doppler at the marked site. The skin monitor was vital. Postoperatively, please continue antibiotics with Unacid i.v.. Feeding via the previously inserted PEG tube. Food build-up after swallowing porridge on the 10th day with unremarkable findings. The still dehisced wound area on the left cervical side can be closed secondarily after the swelling has subsided. Please carry out regular Doppler checks of the monitor postoperatively according to the scheme. Postoperative radio-chemotherapy is certainly necessary for mulicentric hypopharyngeal carcinoma and field cancerization.