First, pharyngoscopy and laryngoscopy again: The exophytic tumor is visible, which extends from the beginning of the posterior wall of the hypopharynx over the lateral wall on the right to the arytenoid region and here in the arytenoid region also into the larynx. Tumor extends to the tip of the hypopharynx. Therefore, surgery with flap coverage is now indicated. Due to the patient's poor condition with renal insufficiency, liver insufficiency and portal vein hypertension as well as heart failure, a free flap is not indicated. Therefore, preoperative RCT is also not possible. The skin is now disinfected and all surgical areas are draped. An apron flap is then created in the typical manner and neck dissection is performed on both sides. Neck dissection on the right: A cranial lymph node conglomerate is visible, which grows towards the sternocleidomastoid muscle and is also connected to the accessorius nerve and reaches the vein. Conglomerate can be dissected from the vein. N. accessorius virtually runs through. Therefore, parts of the sternocleidomastoid muscle and the accessory nerve are included. Exposure of the omohyoid muscle caudally and finally the digastric muscle cranially. Vein can be visualized from caudal to cranial and the lymph node conglomerate can be dissected. Exposure of the internal and external carotid arteries and their branches. The vagus nerve can be visualized and preserved, as can the hypoglossal nerve. This results in a level II-V neck dissection and preservation of the branches of the cervical plexus. Subsequent left neck dissection: Dictation <CLINICIAN_NAME> is still missing. Subsequent tumor resection. Skeletonization of the larynx. Detachment of the suprahyoid muscles from the hyoid bone. Dissection of the hyoid bone on both sides. Subsequent dissection of the thyroid gland including vascular supply by dissection caudally and laterally on both sides. The upper horn of the thyroid cartilage is isolated and the piriform sinus is pushed off on the left, this step is omitted on the right. The epiglottis is then exposed, taking the supraglottic fatty tissue with it, and the pharyngeal cavity is entered. Expose the tumor. Cut around the tumor by at least 1.5-2 cm on all sides. The wall falls to the base of the tongue and at least 70% of the posterior wall of the oropharynx. The left side is dissected with maximum protection of the piriform sinus. The specimen is removed including the larynx, partial preservation of the postcricoid mucosa initially. Separation of the larynx in a typical manner. Suture marking of the mucosal areas on the resected specimen. In addition, marginal sample from the caudal area of the pharyngeal wall to the postcricoid to the left side. Send for frozen section. In the frozen section, carcinoma in situ in all areas, also in the area of the marginal sample. Therefore, a circular resection 1.5 cm wide is performed again, with the sutures placed away from the tumor. Tumor remnants in the area of the base of the tongue and pharyngeal wall on the right in the frozen section. Therefore, another resection and subsequent marginal samples ...................................................... to the right, the pharyngeal side wall and from the entire posterior wall of the oropharynx including the base of the tongue. No more high-grade dysplasia here. Overall, however, field carcinomatization can be assumed despite the surgical R0 situation. The surgical site is now irrigated. Hemostasis. Overall dissection somewhat more difficult due to heavy bleeding during the entire operation as a result of portal hypertension. Overall, due to the patient's poor general condition, indication for a pedicled pectoralis major flap. There is gynecomastia. The flap is therefore drawn slightly more medially than usual. Size 12 x 10 cm. Marking. First lift off a bridge of the deltopectoral area. Then lift the pectoralis muscle and locate the artery. Then cut around the flap including the muscle and lift off the flap with the underlying muscle, whereby the shear sutures are also applied. Dissection of the flap on the pedicle up to the clavicle. Careful protection of the artery here. Then widen the tunnel again. Here again careful hemostasis. Pulling the flap through. Overall, the pectoralis flap is not particularly favorable, as the subcutaneous tissue is significantly thickened due to the gynecomastia. However, the flap can be successively sutured into the defect or to the residual mucosa, which is increasingly preserved at a thickness of 2 cm caudally upwards. A nasogastric tube for feeding was inserted beforehand. A PEG was not inserted because of the ascites. Now myotomy of the cricopharyngeal muscle on the left side, thereby relieving the pharyngo-oesophageal junction. Subsequent Provox prosthesis insertion. Insertion of a 12 mm prosthesis typically without complications due to the thickening of the tracheal wall. Flap suturing under tension due to the thick subcutaneous tissue and the poor malleability of the flap. The flap is then sutured to the left sternocleidomastoid muscle to relieve pressure and reduce the tendency towards retraction. The infrahyoid muscles are sutured caudally over the flap. Careful hemostasis is then performed. Suture back the apron flap and the epithelialization of the tracheostoma and insert a Redon drainage tube on both sides. Insertion of a size 8 tracheostomy tube. The wound in the thoracic area is closed in layers after mobilization of the skin with insertion of a total of 2 Redon drains. Completion of the procedure without complications. Patient transferred to the interdisciplinary surgical intensive care unit for monitoring. Low skin tension in the area of the stalk. Satisfactory skin perfusion on insertion of the flap. Please continue antibiotics, which were started preoperatively, with Unacid for one week. Increased risk of fistula due to the thickness of the subcutaneous tissue. Feeding via the inserted nasogastric tube for at least 10 to 12 days, then, depending on the course of the operation, gruel swallowing and diet build-up if necessary. Overall, cT3-4 hypopharyngeal carcinoma with clear field carcinomatization so that a laryngectomy with subtotal pharyngectomy was performed. Due to the risk factors, the defect was not covered with a microvascular pedicled flap. After receiving the histology, please present at the interdisciplinary tumor conference. Postoperative radiotherapy, possibly with Erbitux, is certainly still indicated.  