First, induction of anesthesia by the anesthesia colleagues. First pharyngoscopy and laryngoscopy by <CLINICIAN_NAME>: The described tumor is found in the hypopharynx on the left, but it is larger and more massive than expected, above all it reaches a thickness and shows submucosal growth size, rather cT2 and growth towards the tip of the sinus as well as towards the aryepiglottic fold and towards the thyroid cartilage. Overall, no indication for laser resection, therefore indication for transoral surgery with subsequent flap coverage. Then sterile washing and draping in the neck area and performance of a tracheotomy by <CLINICIAN_NAME>: injection of 5 ml Ultracaine with Suprarenin additive along the skin incision. Now incision with the 15 mm scalpel and skin incision. Longitudinally directed approx. 5 cm long between cricoid and jugulum. Very short and thick neck. Sharp cutting of skin and platysma. Dissection in depth. Easy exposure of the linea alba. Dissection of this, exposure of the thyroid capsule. Entering with the Overholt clamp and passing under the isthmus. Bipolar coagulation of the isthmus of the thyroid gland. Exposure of the trachea and insertion with the pointed scissors between the 2nd and 3rd tracheal ring using Ethibond suture Creation of a mucocutaneous anastomosis. Now gastroscopy and PEG insertion: Now enter with the gastroesophagoscope and advance into the stomach with air insufflation. Once in the stomach, the stomach is inflated. A spontaneous diaphanoscopy is seen below the costal arch. A PEG is also inserted here using the thread pull-through method. There are no complications. The patient received clindamycin 600 mg perioperatively due to an allergy to amoxicillin and penicillin. Then, the Kleinsasser tube and the spreading laryngoscope were inserted and the tumor was inspected by <CLINICIAN_NAME>. The tumor was significantly larger than previously described and could no longer be resected by laser. The decision was therefore made to perform a transcervical tumor resection using flap coverage. Repositioning of the patient and sterile draping of all relevant surgical areas. First, creation of an apron flap in the typical manner up to the level of the hyoid bone or submandibular gland. Then radical neck dissection on the left by <CLINICIAN_NAME>: Lymph node conglomerate is seen cranially, which infiltrates the sternocleidomastoid muscle. First visualization of the V. facialis from cranial to caudal until it flows into the V. jugularis interna, here already caking with the lymph node conglomerate is visible. Therefore, exposure of the internal jugular vein further caudally, here some outlets to the thyroid gland can be dissected and preserved, as well as other jugular outlets. Further dissection cranially shows infiltration into the wall. Resection is therefore now necessary. The facial vein is ligated first. Subsequent medial exposure of the common carotid artery, external carotid artery and internal carotid artery; these can each be dissected, as can the vagus nerve and hypoglossal nerve. Then cranial exposure of the internal jugular vein successively after dissection of the lymph node conglomerate of the digastric muscle. The hypoglossal nerve can also be dissected here. Then caudal transection of the internal jugular vein and double ligation, once using the puncture technique. The caudal branches can remain intact. The sternocleidomastoid muscle is then severed. This is also resected from the cranial side near the insertion. The accessory nerve runs into the lymph node conglomerate and cannot be preserved. Exposure of the upper part of the internal jugular vein close to the base of the skull, which is then ligated twice and removed. The remaining parts of levels II to V are then evacuated, exposing and preserving the branches of the cervical plexus. Here too, several positive lymph nodes, especially in level V. Overall, several lymph node metastases clinically clearly on the left. Clearing of the anterior neck specimen with visualization and preservation of the superior thyroid artery. Then transcervical resection of the hypopharyngeal carcinoma with partial laryngeal resection by <CLINICIAN_NAME>: First visualization of the hyoid bone and dissection of the muscles. Hyoid bone is resected. Infrahyoid muscles are cut down caudally with the thyroid lobe including the superior thyroid artery. Pharyngeal wall is exposed. The carotid artery is looped with the vagus nerve using the vessel loop and pulled slightly to the side; the superior laryngeal nerve is also exposed and pulled cranially using the vessel loop. Then enter the pharyngeal space at the level of the hyoid bone. Exposure of the tumor. The tumor is then cut around with a safety margin of 1.5 to 2 cm on all sides. The posterior wall of the hypopharynx, the piriform sinus up to the esophageal entrance or tip of the sinus, as well as part of the arytenoid fold, tumor also grows posteriorly towards the thyroid cartilage, therefore lateral resection of approx. 50 % to 60 % of the thyroid cartilage. A macroscopic resection is achieved well within the healthy tissue. The tumor is finally marked with sutures. A marginal sample is taken from the arytenoid region up to the piriform sinus entrance from the medial side. Like the specimen, this is also thread-marked for frozen section evaluation. In the frozen section, both the tumor and the marginal sample are healthy. Therefore R0 resection. Subsequent careful hemostasis and irrigation of the wound area. Neck dissection on the right side through <CLINICIAN_NAME> and <CLINICIAN_NAME>. After creating the apron flap, sharply dissect the skin platysma flap with the scalpel. The external jugular vein is not exposed. The auricularis magnus nerve is exposed and cut. Dissection along the anterior edge of the sternocleidomastoid muscle in depth, the accessorius nerve is exposed and spared. The posterior abdomen of the digastric muscle is also exposed, the submandibular gland is seen medially, which is also exposed without difficulty. The omohyoid muscle is shown caudally, which represents the borders of the neck dissection. Here as a vascular sheath directly in the depth below the neck preparation. The internal jugular vein is exposed from caudal to cranial, there is no injury to the structures here. The superior thyroid vein and the facial vein are dissected and spared. The external and internal carotid arteries, the vagus nerve and the cervical artery are exposed medial to the jugular vein. The neck preparation is now detached in level IIb, followed by level IIa, sparing the accessorius nerve. Levels III, IV and V are also detached without difficulty. The plexus branches are visualized and specifically protected. A chyle fistula occurs caudally when the preparation is removed. The anterior neck preparation is now almost exposed and dissected along the V. facialis and the V. thyroidea superior. Removal of the split skin: A split skin from the left thigh measuring 11 x 8 cm is easily removed using a dermatome. Then lift the radialis graft parallel to it, here see the corresponding dictation by <CLINICIAN_NAME>. Palpatory identification of the distal radial artery. Marking of the flap boundaries (8.5 x 14 cm) on the distal forearm, proximal to the flexor retinaculum, with an S-shaped incision running proximally into the cubital fossa. Incision of cutaneous and subcutaneous tissue starting proximally. Identification and visualization of the venous confluence in the cubital fossa. Identification of the cephalic vein and dissection of the vein distally with integration into the radial graft margin. Identification of the ramus externus of the radial nerve and elevation of the radial portion, leaving the peritendineum of the tendons of the brachioradialis muscle intact. Subsequent ulnar incision down to the forearm fascia. Incision of the fascia and subsequent subfascial elevation of the ulnar edge of the graft up to the tendon of the flexor carpi radialis muscle. Care is taken to leave the peritendineum on the flexor tendons and to spare the ulnar artery. Identification of the distal radial artery and trial clamping with a vascular clamp. After 5 minutes with good oxygen saturation measured by pulse oximetry (measured on the index finger), the vessels are removed with subsequent ligation (Prolene 6.0). Successive detachment of the flap pedicle from the M. pronator quadratus and M. flexor pollicis longus with ligation of the outgoing perforators using a vessel clip into the cubital fossa. Exposure and protection of the radial nerve on the medial side of the brachioradialis muscle. Exposure of the brachial artery, V. mediana cubiti, A. ulnaris. First removal of the radial artery, then of two veins of the superficial venous system. Vascular ligation by means of a bypass ligature (artery) and vascular clip (veins). Subtle hemostasis in the area of the wound bed using bipolar coagulation forceps. Two-layer wound closure in the area of the proximal forearm. Covering of the graft bed with split skin from the right thigh in the usual manner. Suturing of preparation swabs. Application of a wound dressing and a forearm splint. Completion of the graft lift without complications. Removal of the radialis graft by <CLINICIAN_NAME> and beginning with the arterial anastomosis to the superior thyroid artery. Then 3 venous anastomoses twice to the facial vein and then additionally to a direct outlet to the internal jugular vein. Then insertion of the graft into the defect and suturing of the graft, which is relatively difficult, especially in the area of the base of the tongue, due to existing tension. The graft is slightly too wide in the upper area and also in the lower area. The graft still needs to be trimmed slightly at the esophageal entrance. This is possible as the anastomosis is already in place. Then sutures are placed and the esophageal entrance is reconstructed using the radialis graft. Then successive suturing of the remaining graft in the pharyngeal and tongue base area. The flap stalk itself is extremely thick due to severe adiposity on the forearm, making it relatively difficult to integrate the raised skin monitor into the suture. Initially, an attempt is made to cut an additional hole in the apron flap and pull the skin monitor through, but this causes tension and twisting in the flap handle, so this is removed again and the hole is sutured. The skin monitor is ultimately integrated into the skin suture next to the tracheostoma. The tracheostoma was sutured with Ethibond sutures. At the end, 2 flaps are inserted on both sides and the wound is closed in two layers in the neck area. Insertion of a tracheostomy tube. Suturing of a tracheostomy tube and the patient is ventilated and admitted to the intensive care unit. Please continue antibiotics for at least 3 days. Daily flap checks on the skin monitor, if necessary also directly via a mouth spatula. In addition, a marker was placed for a Doppler so that the flap can be checked three times. Flap control according to the usual scheme.