First, laryngoscopy and pharyngoscopy again: The exophytic tumor is seen, which is located in the piriform sinus on the left, passes to the vallecula of the epiglottis and also grows into the larynx via the arytenoid fold. Transition also to the postcricoid region. Indication for surgery thus confirmed. Skin disinfection, injection of a total of 20 ml Ultracaine 1% with adrenaline in the area of the sides of the neck and sterile draping of all surgical areas. First, create an apron flap in the typical manner, subplatysmal to the level of the hyoid bone and submandibular gland. Then neck dissection on both sides, initially on the right: same procedure on both sides. Dissection of the lymph node packages from the sternocleidomastoid muscle. Exposure of the cervical vascular sheath, internal jugular vein, internal carotid artery, external carotid artery, vagus nerve, accessorius nerve, hypoglossal nerve. The lymph nodes are then removed from 2 to 5, followed by neck dissection on the left side in the same way. All structures are exposed and preserved as on the opposite side, including the superior thyroid artery. This is followed by laryngectomy with subtotal pharyngectomy: skeletonization of the larynx. Dissection of the suprahyoid muscles from the hyoid bone, which is removed due to the height of the tumor. Skeletonization of the grand......... on the right side and as far as possible on the left side. On the right, the constrictor pharyngeus is dissected from the laryngeal skeleton. This must be largely omitted on the left side, where the constrictor muscles are largely resected as well. Also resection of infrahyoid muscles and lymph nodes up to level VI. Entry into the larynx from the cranial paramedian on the right. Release of the epiglottis, exposure of the tumor. The tumor was previously operated on transorally from the cranial side and the cranial resection margin was marked. A marginal sample from the cranial resection area was in healthy tissue. The tumor is now resected on all sides with a safety margin of at least 1.5 to 2 cm, taking into account the cranial resection margins. Pharynx falls largely to the posterior wall on the left. The postcricoid region is also resected up to just in front of the esophageal entrance. The trachea had already been exposed previously. The lobes of the thyroid gland were clamped, severed and treated with puncture ligatures. The thyroid gland was pushed off caudo-laterally. The larynx was then removed, leaving the trachea extended cranially and dorsally. Then mark the laryngectomy and pharyngectomy specimen. A relatively wide marginal sample is taken from the left pharyngeal wall area and a marginal sample from the tongue base area. However, with free tumor margins around the tumor specimen, the margin sample, which was also taken from the pharyngeal wall area, still shows carcinoma in situ. This indicates discontinuous growth. The marginal sample from the base of the tongue was clear. Further resection in the entire pharyngeal wall area from caudal to cranial left. Removal of a representative marginal sample. This still shows moderate dysplasia. Thus overall R0 situation. No evidence of invasive carcinoma. A 2-4 cm strip of residual pharynx remains. Defect coverage using a radial flap is therefore necessary. The radial flap is removed from the left forearm. Mark the size of the flap, which is 15 x 8-9 cm. Create a tourniquet. Then lift the flap first from the ulnar side, from here extend the incision in the crook of the elbow. Subsequent mobilization of the flap from the radial side, including the superficial venous system and underneath the fascia. Exposure of the vascular pedicle below the brachioradialis muscle. Mobilization of the flap from below after the radial artery, which is supplied with blood by means of a tourniquet, has been removed. Successive elevation of the flap with clipping or bipolar supply of branches. The connection between the deep and superficial venous system is shown in the crook of the elbow. A total of 3 venous connections of the confluence or cephalic vein can be visualized. Good perfusion after opening the tourniquet. Flap remains in perfusion until the R0 situation is established. Then remove the flap. Ligatures in the area of the veins and puncture ligature with 4-0 prolene in the area of the artery shortly before entering the brachial artery. Remaining hand well perfused. Flap is flushed with heparin and preserved. A piece of full-thickness skin of the appropriate size is removed from the groin area in the typical manner. Here a groin after skin mobilization. Closure in layers using multi-layered subcutaneous sutures and back-stitch skin sutures after insertion of a Redon drain with relatively little tension. The forearm wound is closed in layers in the cranial area in a typical manner. The defect is now covered by the full-thickness skin graft and the full-thickness skin graft is successively incorporated here using 4-0 Ethilon sutures. A Hydrogel-Mebilex dressing is then applied. Application of loose compresses. Wrapping in absorbent cotton. Fitting of a Cramer splint and wrapping of the arm with an elastic bandage. Then cover the defect with a radial flap: Radialis flap is inserted into the defect and successively incorporated using 3-0 Vicryl single button sutures. Complete tension-free closure. Flap pedicle is transferred to the right side. After conditioning the vessels, first anastomosis of the radial artery with the superior thyroid artery using 8-0 Ehtilon single button sutures. After opening the clamps, good arterial flow and good venous return. The vein is confluent with the radial vein and is anastomosed with an outlet from the facial vein using a 2.5 mm coupler; good venous return also after opening the clamps. After conditioning, the cephalic vein is anastomosed with the external jugular vein using a 2.5 mm coupler; good venous flow can also be registered here. The residual veins are clipped and bipolized. Careful irrigation of the surgical site and hemostasis. Wound closure in layers with insertion of a Redon drain on both sides. Particularly deep fixation on the right in the anastomosis region. Trachea is epithelized in a typical manner. Finally, insertion of a 10 mm tracheal cannula which is fixed with sutures. No dressing. Patient goes to intensive care unit for postoperative monitoring. Please continue intraoperative therapy with heparin 500 E/hour for 5 days. Flap control by means of Doppler and clinically via laryngoscope insertion according to scheme. Please continue antibiotic therapy with Unacid, which was started intraoperatively, for at least 2 days. Nutrition via the previously inserted PEG tube for at least 10 days. Total cT4a cN2c hypopharyngeal carcinoma left. Discuss postoperative radiotherapy versus radiochemotherapy.  