Dictation <CLINICIAN_NAME>: After induction of anesthesia and intubation by the anesthesia colleagues, the primary tumor region is first inspected. After entering with the Kleinsasser tube, the exophytic and ulcerated tumor is already visible in the area caudal to the left tonsil, spreading caudally over the lateral pharyngeal wall and extending into the piriform sinus, filling it completely and extending over the anterior wall and into the medial wall, infiltrating the larynx. Therefore confirmation of the indication for laryngectomy. Free postcricoid and esophageal entrance. The entire right side is also tumor-free, but due to the elongated, broad tumor course in the area of the pharyngeal side wall, reconstruction is probably required. A nasogastric feeding tube is now inserted under visualization. Repositioning of the patient. Lifting of an apron flap by cutting through the skin and subcutaneous tissue. Dissection and cranial preparation of the platysma. Start with neck dissection of the right side. Dissection of the sternocleidomastoid muscle and preservation of the external jugular vein. Exposure of the omohyoid muscle. Release of the submandibular gland and exposure of the digastric muscle. Clearing of the anterior neck preparation with careful protection of the hypoglossal nerve and superior thyroid artery. A true facial vein does not exist. Free preparation of the internal jugular vein. Cranial exposure of the accessorius nerve. Clearing of the posterior neck area with careful protection and exposure of the cervical plexus roots. Macroscopically no conspicuous nodules here. Careful hemostasis. Turning to the opposite side. Now the same primary procedure on the left side. Exposure of the sternocleidomastoid muscle while preserving the external jugular vein. Free preparation of the sternocleidomastoid muscle, omohyoid muscle. Release of the submandibular gland and exposure of the digastric muscle. Clearing out the anterior neck preparation while carefully protecting the superior thyroid artery, hypoglossal nerve and the slender facial vein. Complete the neck dissection after exposing the accessory nerve in the case of conspicuous nodes in the jugular-facial angle, exposing the cervical plexus roots, the common carotid artery and the vagus nerve corresponding to the opposite side on the left. Resection up to level V b. Careful check for lymphatic leakage. Dry conditions here. Careful hemostasis. Turn to tumor resection. Detachment of the infrahyoid musculature. Skeletonization of the larynx on the right side. Careful and complete release of the piriform sinus. On the left side, the attempt to detach the thyroid cartilage horn already reveals an adhesion or direct adherence to the tumor; if partially opened here, the suture is marked in the sense of a suture closure for later marking and covering of the margins. Skeletonize the cricoid cartilage and trachea while exposing and detaching the thyroid gland. Now enter enorally in the area of the vallecula on the right side, widen along the aryepiglottic fold and proceed in a mucosa-sparing manner. After widening the pharyngotomy, a good overview is now obtained. As described above, the tumor infiltrates caudal to the tonsil. Incision with a safety margin. Somewhat vulnerable conditions in the area of the glossotonsillar groove, otherwise macroscopically all around in sano incision of the tumor. Good control of the deep infiltration. Supply and removal of the lingual artery on the left side. Largely sparing of the postcricoid mucosa and removal of the tumor macroscopically in sano. The marginal specimen is now largely removed from the specimen. The site already described in the area of the thyroid cartilage horn on the left or the pharyngeal side wall here is additionally covered in the area of the soft tissue. In addition, in situ marginal sampling of the described vulnerable area completely in the base of the tongue up to the tonsil lobe. In the frozen section diagnostics, all tumor samples are now diagnosed as dysplasia and carcinoma-free, therefore an R0 situation can be assumed here. Careful hemostasis. Dictation <CLINICIAN_NAME>: Defect reconstruction. Inspection of the defect. There is a hypopharyngeal defect starting at the soft palate up to the esophageal entrance. More than half of the pharyngeal mucosa is missing on the soft palate and in the upper part of the hypopharynx. Primary suturing is not possible in this area. A quarter to a third is missing in the distal area at the entrance to the esophagus. Primary suturing is still acceptable here. Decision to reconstruct the defect with an anterolateral transfemoral graft from the right. Intraoperative demo again to <CLINICIAN_NAME>. Then turn to the thigh. First Doppler the perforating vessels. Five good perforator vessels can be identified, three of which can be claimed as main perforators. Mark the graft 12 x 7 cm so that the doubled perforator vessels are centrally located in the area of the graft. Incise the upper edge. Expose the fascia and the rectus femoris muscle. Exposure of the intermedius muscle and the sulcus. Exposing the descending ramus, the circumflex femoral artery and locating the outlets of the perforating vessels. This was successful without any problems. The perforating vessels are dissected from the pedicle to the periphery in the direction of the muscle and skin. Cut around the entire graft and remove the distal end of the stalk. Then develop the graft while protecting the perforator vessels. Some muscle is left around the perforator vessels on the posterior surface. Deposit the pedicle relatively far proximally. A good artery and two veins can be elevated. The nerve is severed. Bipolar coagulation. Insertion of a Redon drain and direct wound closure in the area of the thigh. Now turn to the pharyngeal defect. First conditioning of blood vessels. The vascular situation is very poor. There is only a stump of the superior thyroid on both sides. There is virtually nothing left of the venous connecting vessels except for an external jugular vein and the internal jugular vein. The stump of the superior thyroid on the left side is conditioned as well as the external and internal jugular veins. First fitting of the transplant. Sutures are placed in the area of the oropharynx and hypopharynx on the left side. Suturing in the graft. This is very difficult as the patient cannot recline the head and the graft has to be inserted very far cranially on the soft palate and at the base of the tongue. Finally, complete pharyngeal closure by the graft and primary pharyngeal suture in the distal area. Then conditioning of the flap vessels and start with the anastomosis of the artery. This is successful without any problems. Then anastomosis of the external jugular vein with a graft vein. This is very difficult due to a large difference in caliber. This difference in caliber can only be partially compensated for by cutting the graft vein at an angle. Another vein must be placed end-to-side on the left internal jugular vein. This is also not easy. In the end, very good pedicle pulsation and extremely good reflux in the veins. At the end, the tracheostoma is sutured. The apron flap is folded back. Redon drains inserted beforehand. Graft control from transorally. Good graft perfusion here. The patient goes to the intensive care unit ventilated. Please continue 3 x 3 g Unacid for 24 hours postoperatively as well as daily flap checks according to the usual schedule.   