A PEG tube is inserted at the start of the operation. For this, insertion with the flexible gastroesophagoscope. Pre-viewing into the stomach. Then good diaphanoscopy. Insertion of the gastric tube using the thread pull-through method. This is successful without any problems. Induction of anesthesia and intubation by the anesthesia colleagues, then the tumor was inspected again with the Kleinsasser tube. The tumour is located in the hypopharynx on the lateral and anterior wall. It has a centrally deep ulcer, which is not accessible to the originally planned laser resection in any way, as the extension into the soft tissues of the neck cannot be determined and laser resection is therefore out of the question. Tracheotomy by <CLINICIAN_NAME>. Palpation of the thyroid incisura, cricoid and jugulum as well as the anterior edge of the sternocleidomastoid and marking with a pen. Now mark the skin incision 3 transverse fingers above the jugulum, just below the cricoid cartilage. Make a horizontal incision along a skin fold, 7 cm long in total. Now enter with the 15 mm scalpel and sharply cut through the skin, the subcutaneous tissue and the platysma. The anterior jugular vein is now exposed. This vein is dissected, clamped, ligated and cut. Further dissection in depth with exposure of the infrahyoid musculature. The linea alba is dissected and the musculature is displaced to the side. The thyroid capsule is now exposed and the Overholt clamp is used to enter between the isthmus and the cricoid cartilage. The isthmus is undercut and bipolarized, coagulated and severed. There is no relevant bleeding. Now both thyroid lobes are pushed to the side and incision is made with the pointed scissors between the 2nd and 3rd tracheal cartilage ring. Creation of a Björk flap. Tracheostomy suture with Ethibond. Re-intubation of the patient to a 9 mm cannula. No complications. Then sterile washing and draping. Now start with the apron flap and neck dissection on the left side. A 20 x 15 cm metastasis is seen here, which completely infiltrates the cervical vascular sheath and the sternocleidomastoid muscle. Start with the dissection in the caudal area, here the sternocleidomastoid muscle is removed and the internal jugular vein is exposed, which is almost completely obliterated. Exposure of the common carotid artery from which the mass can still be pushed off in the deep part. This is very difficult as there is only a thin layer between the metastasis and the artery, which can, however, be dissected relatively well up to the bulb. The wall of the carotid artery is infiltrated in the area where the external carotid artery leaves, and the mass cannot be pushed off here. Further dissection in the cranial area. Separate the sternocleidomastoid muscle in the cranial region, then expose the obliterated internal jugular vein. This can also be removed. It is clear that the tumor is growing cranially to the base of the skull, then extremely laborious dissection of the metastasis from the base of the skull. This is finally successful. Now removal of the external carotid artery in the bulb area. However, the tumor must be left on the carotid artery, as it cannot be dissected off here. Removal of the entire metastasis. Now consult with <CLINICIAN_NAME>, who recommends consulting a vascular surgeon with the question of a replacement graft. Now consult <CLINICIAN_NAME> from the vascular surgery department. He sees no problem with an end-to-end anastomosis. As the carotid artery is elongated due to the tumor displacement, the bulb area can be resected with a safety margin. Plaque removal is now performed by <CLINICIAN_NAME> and an end-to-end anastomosis is performed. Then transition to tumor resection. Entry into the pharynx from the lateral cranial side. Exposure of the tumor and resection of the tumor. The tumor grows clearly into the thyroid cartilage, so part of the thyroid cartilage is also removed. The superior laryngeal nerve must also be removed and the arytenoid on the left side can just be left standing. Now measure the defect and lift the radialis graft by <CLINICIAN_NAME>. Neck dissection on the right by <CLINICIAN_NAME>: elevation of a platysma flap together with <CLINICIAN_NAME>. Successive dissection of the platysma and flaps of the platysma flap cranially. Exposure of the anterior border of the sternocleidomastoid muscle. Exposure of the cervical vascular sheath and dissection of the internal jugular vein, the common carotid artery, the bifurcation as well as the external and internal carotid artery. Exposure and sparing of the vagus nerve and accessorius nerve. Displacement at the end of the operation. Re-embedding of the vagus and accessor nerve in the sense of a neurolysis. Exposure of the digaster venter posterior muscle. Exposure of the hypoglossal nerve and protection of the same. Displacement at the end of the operation. Re-embedding of the nerve in the sense of a neurolysis. Exposure of the right submandibular gland while protecting it. First develop the lateral neck preparation while sparing all the structures mentioned. The same applies to the median neck preparation. Postoperative careful hemostasis. During the operation, care was taken to preserve the venous and arterial connecting vessels. Elevation of the radialis graft by <CLINICIAN_NAME>: Drawing of the radialis graft on the distal forearm (6 x 10 cm) with additional monitor in the area of the flap pedicle. Demonstration on <CLINICIAN_NAME>. Skin incision on the proximal forearm with incision around the skin monitor and the entire radialis graft. Subcutaneous preparation between radialis graft and skin monitor. Incision of the forearm fascia and exposure of the flexor tendons. Subfascial preparation of the radialis graft, initially from the ulnar side, with safe protection of the ulnar artery. Particular care is taken to leave the peritendineum attached to the tendon. Identification of the distal section of the radial artery with the comitant veins. Radial incision of the deep forearm fascia lateral to the cephalic vein. Reliable identification of the external ramus of the radial nerve. Separation of the radial artery on the distal forearm. Elevation of the graft with constant vascular ligation using vascular clips of the perforator vessels. Exposure of the confluence in the area of the proximal forearm/elbow. A good venous vascular network can be seen. Visualization of the exit of the radial artery from the brachial artery. Safe removal first of the radial artery and then of the venous vessels. Completion of graft elevation without complications. Suturing of the graft and anastomosis of the vessels, for this the superior thyroid artery is used on the right side, on the left side there are no vessels except for the bare carotid artery. Unfortunately, in the case of a previous operation, only the external jugular vein is available as a connecting vessel, which is also used. The defect is closed with split skin from the right thigh through <CLINICIAN_NAME> and <CLINICIAN_NAME>. Inspection of the tendons for this. Some of these are very exposed and must be sutured over with muscle. Application of retaining sutures to reduce the defect. Adjustment of the split skin and suturing. Swabs are sutured onto areas where the split skin has no contact with the surface. At the end of the procedure, the skin is covered with a stretched compress and a dorsal forearm splint is applied. At the end, suture the skin monitor and insert a Redon drain on the left side and a flap on the right side. Insertion of the tracheostoma, two-layer wound closure and completion of the procedure without complications and good graft perfusion. In the meantime, the operation had to be interrupted several times as the patient developed a critical ventilation situation. This also necessitated an intraoperative bronchoscopy by the anesthesia colleagues. However, this did not reveal any pathological findings. Continue antibiotics for at least 24 hours, regular graft and wound checks according to the usual schedule. The patient is ventilated and admitted to the intensive care unit. The patient's circulation is unstable and he is in a critical pulmonary situation that requires close monitoring.