After induction of anesthesia and intubation via the patient's existing tracheostoma, the operation is first planned during pharyngoscopy. This reveals a right-sided, exophytic tumor, which extends in the area of the oropharyngeal side wall to the tonsil and then affects the pharyngoepiglottic fold, involves the entire right piriform sinus and also clearly affects the postcricoid region in the area of the right side, almost completely encloses the lateral piriform sinus laterally, but only slightly affects the posterior pharyngeal wall posteriorly. In the larynx, the epiglottis is partially affected, the right aryepiglottic fold, the right arytenoid cartilage and the pocket folds are completely affected. The tumor grows over the interarytenoid region into the postcricoid region. The left arytenoid cartilage and the left aryepiglottic fold are tumor-free, as are the vallecula and more than half of the epiglottis. Deep down, the left piriform sinus is completely free, but the entrance to the esophagus is stenosed and it is not possible to determine exactly to what extent the entrance to the esophagus is affected, but this can be assumed based on the fixation. Discussion of findings with <CLINICIAN_NAME> and procedure for surgery. First, formation of an apron flap, which extends from the tracheostoma to the far lateral side. Then create the apron flap, partly with the help of the BiClamp system. Expose the sternocleidomastoid muscle on both sides and form the apron flap up to above the hyoid bone. Now turn to the neck dissection of the right side. The very prominent, partially fixed lump can be easily palpated here. An attempt is first made to dissect the sternocleidomastoid muscle and the internal jugular vein, but it quickly becomes apparent that they are completely infiltrated by the tumor. The decision is now made to perform a radical neck dissection. The posterior digastric venter muscle and the submandibular gland are exposed and isolated. The sternocleidomastoid muscle is then imaged in the cranial region. The accessorius nerve can also be identified here and initially spared. The sternocleidomastoid muscle is then resected in its caudal area and the same is done in its cranial area, taking care to spare the part of the accessorius nerve that goes towards the trapezius muscle. Now continue to form the lateral border of the neck. Deep exposure of the plexus branches and the scalene muscles in their lateral area. Then complete visualization of the internal jugular vein in its caudal and cranial course. Identify the hypoglossal nerve and spare the last one. The internal jugular vein is now ligated twice and separated cranially and caudally. Prior to this, the common carotid artery and the vagus nerve were identified and spared. In addition to the large tumor, which appears to be fixed towards the thyroid cartilage, there are also additional tumor conglomerates in level IIa. Now turn to the medial neck preparation. To do this, follow the omohyoid muscle anteriorly and the digastric muscle anteriorly. Then form the medial neck preparation along the thyroid cartilage muscles. This reveals a site between the thyroid cartilage and the hyoid bone where the tumor conglomerate is connected to the actual tumor per continuitatem. This site is cut and marked on both the thyroid cartilage and the tumor. The medial neck preparation is then followed up, sparing the hypoglossal nerve. Exposure of the superior thyroid artery, which is clamped. Then expose the carotid artery from caudal to cranial and also the vagus nerve from caudal to cranial. Now turn again to level II b and here further development of the lateral neck preparation from cranial to caudal while sparing the plexus branches. At the end, the entire neck preparation is formed in a large block. Now turn to the neck dissection of the left side. No large lymph node metastases are visible here, therefore expose the sternocleidomastoid muscle. Formation of the anterior border and visualization of the posterior digastric venter muscle and the omohyoid muscle. Identify the accessorius nerve and then form the internal jugular vein from caudal to cranial. Here, after identifying and sparing the vagus nerve, the lateral neck preparation is formed while sparing the accessorius nerve and plexus branches. Then turn to the medial neck preparation. Trace the omohyoid muscle, trace the digastric muscle anteriorly and expose and skeletonize the submandibular gland and spare the facial vein. After identifying the hypoglossal nerve, the medial neck preparation is also formed, whereby the superior thyroid artery is also spared. Preparation for laryngectomy/partial pharyngectomy. Preparation of the tracheostoma. Exposure of the right thyroid gland from the trachea while protecting the blood supply. Then expose the cervical vascular sheath on the left side from the laryngeal preparation down to the vertebral body. Further cranial ligation of the bundle of the superior laryngeal nerve and skeletonization in the upper area with monopolar coagulation of the hyoid bone. Now the constrictor pharyngeal muscle on the left side of the thyroid cartilage is also cut with the monopolar and the upper thyroid cartilage horn is exposed. Then, with the help of the Freer raspatory, expose the piriform sinus from the inner side of the thyroid cartilage. Now turn to the right side. As described above, this shows a tumor breakthrough between the thyroid cartilage and hyoid bone, which is why the constrictor pharyngis muscle is not exposed here. Only the carotid artery is exposed from the laryngeal preparation. It can also be seen that the right lobe of the thyroid gland is severely regressively altered with cystic areas and a fixation to the tumor. For this reason, the right thyroid lobe is also isolated from the surrounding tissue, with the inferior thyroid artery and the middle thyroid vein ligated and ligated. The right thyroid lobe thus remains on the subsequent tumor specimen. Now, after previously skeletonizing the hyoid bone, the transoral localization of the epiglottis and the submucosal dissection along the left lingual epiglottis cartilage is performed through the neck. The pharynx is then opened on the left side and initially dissected along the left aryepiglottic fold. It can be seen that the tumor clearly involves the oropharynx on the right side, as already described above. The entire right hypopharynx is full of exophytic tumor. The resection is now extended to the right via the right base of the tongue, then to the right tonsil. Previously, the internal carotid artery was traced far to the cranial side in order to isolate it from the pharynx and the lingual artery was ligated and cut. The resection is now extended to the left via the aryepiglottic fold to the left arytenoid cartilage. However, the postcricoid region is affected up to the midline and cannot be preserved. An attempt is made to preserve the left piriform sinus, but it is suspected that the tumor is also growing submucosally through the thyroid cartilage to the left piriform sinus. A frozen section sample is therefore taken here, which is later found to contain tumor. The resection now continues caudally. On the right side, a good part of the posterior pharyngeal wall is resected, on the left side a little of the postcricoid region can be spared. The esophageal entrance is now reached. It can be seen here that the tumor infiltrates the esophageal entrance on its anterior and right side. The specimen is removed here and a marginal sample is also taken, which is later found to be tumor-infested. Another problem area is the base of the tongue, which is also infiltrated at certain points and, after consultation with <CLINICIAN_NAME>, it is suspected that infiltrated regions repeatedly appear between the base of the tongue and the esophageal opening on the right side. Therefore, after careful assessment of the situation, <CLINICIAN_NAME> decided to perform a complete pharyngectomy and also a resection in the area of the esophageal inlet. Prior to this, part of the base of the tongue is resected and a frozen section is performed again, which is later found to be tumor-free. This is followed by pharyngectomy and a myotomy of the upper esophageal sphincter in the caudal region and a resection in the anterior and right-accentuated region. All frozen sections are later found to be tumor-free. Radial flap elevation and the formation of a complete pharyngeal replacement are now performed, which is dictated separately by <CLINICIAN_NAME>. The resulting defect in the area of the left forearm is approximately 10 x 15 cm long and is removed with 2 strips of split skin, 0.7 mm thick, from the area of the right thigh and then painstakingly sutured in place. Finally, the Mepilex insert is applied to both regions, the thigh and the forearm, and the forearm is bandaged with a splint. Dictation <CLINICIAN_NAME> Patient with histologically confirmed incontinuitous growing cT4a laryngeal carcinoma on the right. Therefore above mentioned surgical indication. Flap coverage included in the surgical planning preoperatively. After completion of the pharyngectomy, the marginal specimens in the tongue base area and the circular marginal specimen in the esophageal entrance area were finally free of carcinoma. The circular pharynx must now be replaced. Now remove the radial lobe: mark a flap 9 or 10.5 cm wide and 15 cm long on the left forearm. Also mark a skin monitor island. Successive cutting around the flap at the marked borders subfascially, the flap is finally lifted from all sides. Lifting is performed with the skin monitor including the superficial venous system. Exposure of the vascular pedicle after dissection of the brachioradialis muscle. Finally, distal placement of the flap on the radial artery and vein. Here, 4-0 prolene puncture ligation is performed on both sides. Successive lifting of the flap along its pedicle, taking the superficial venous system and the skin monitor with it. Outgoing vessels are successively clipped or bipolized. Exposure of the deep and superficial vascular pedicle in the crook of the elbow. The radial artery is placed in front of the interosseous artery and sutured over. Finally, the cephalic vein and a further medially larger outgoing vein are removed in the direction of the basilar vein. The superficial and deep venous systems are connected and have an outflow via these two veins. The most careful hemostasis was performed in the area of the flap before the vessels were removed. Subsequently, careful hemostasis was also performed in the area of the forearm. Successive closure of the forearm, primarily in the cranial area. Depending on the skin defect, 0.7 mm thick split skin is now removed using the dermatome. This is successively sutured into the forearm skin defect. Complete tension-free coverage of the skin defect on the forearm. A hydrocolloid lavanide-Mepilex dressing is then applied. Loosely placed swabs are placed over this. Wrap the forearm in absorbent cotton. Wrap an elastic bandage around the splint. The arm is then inserted. This is followed by the total pharyngeal set using the radial flap: successive suturing of the flap, initially caudally with 4-0 Vicryl single button sutures, paying strict attention to sufficient residual lumen thickness at the neopharyngo-oesophagial junction. Passage is finally easy to pass with the finger. The esophageal entrance is plastically widened in the sense of a continuous myotomy with mucosal transection. The appropriately shaped radial flap is now sutured into the incision. Successive suturing of the flap also from the cranial side with Vicryl 3-0 single button sutures, whereby a tension-free closure is achieved at the junction of the base of the tongue or tonsil lobe and radialis flap. Laterally, the radial lobe is sutured to itself. Over-sewing in the lateral area and also caudally and cranially at the transition to the base of the tongue in a second layer. The vessels on the sides of the neck are then conditioned. The left side of the neck is selected. The superior thyroid artery is selected. After conditioning the arteries, the radial artery is sutured end-to-end with the superior thyroid artery using 8-0 Ethilon single-button sutures. After opening the clamp, good arterial flow and good venous return. This is followed by 2 venous anastomoses between the main outlets and the facial vein. After conditioning the vein, the smaller vein is first anastomosed using a 2/5 coupler and finally the larger vein is anastomosed using a 3/0 coupler. In each case, after opening the clamps, good venous return, positive smear phenomenon. At the end, good venous return, positive smear phenomenon. The pedicle is now placed in such a way that kinking of the vessels is largely prevented. For this purpose, the skin monitor is placed in the middle over the flap. This is followed by extensive hemostasis of the entire wound area on both sides. Redon drainage on both sides. Repositioning of the apron flap. This is opened medially and the skin monitor is sutured in place without tension. Subsequent successive closure of the neck wounds in layers with epithelialization of the tracheostoma. Finally, insertion of a 10 mm tracheostomy tube which is fixed with sutures. Postoperatively, the patient is ventilated and admitted to the intensive care unit. Please continue intraoperative antibiotic treatment with Unacid for 1 week. Please continue heparin perfusor with 500 E/hour for 5 days. Feeding via PEG tube for 10-12 days, then gruel and, if necessary, diet build-up. Check the flap clinically on the skin monitor and by Doppler according to the scheme for 5 days. Overall, cT4a cN2c hypopharyngeal carcinoma with invasion into the larynx and continuous growth into the soft tissues of the neck. Postoperative RCT is certainly indicated, but this should be discussed again in the interdisciplinary tumor conference in view of the concomitant diseases.