First, pharyngoscopy and laryngoscopy again: The exophytic tumor is visible, which starts below the tube, runs over the tonsil lobe to the hypopharyngeal entrance, macroscopically also shows clear further submucosal infiltrations than macroscopically recognizable. The base of the tongue is only infiltrated at the edge, otherwise free. In conjunction with the CT, the above indication was confirmed. Then transfer for PEG insertion: insertion of the esophagoscope. A 9-gauge abdominal wall tube is inserted in the typical manner. This is fixed to the abdominal wall. No complications. Then repositioning for modified radical neck dissection and tracheotomy: start with the left side. First skin incision in the typical manner. Exposure of the sternocleidomastoid muscle. Dissection ........ Dissection. Exposure of the omohyoid and digastric muscles. Exposure of the cervical vascular sheath, internal and external carotid artery, internal jugular vein, vagus nerve, accessorius nerve and hypoglossal nerve. Then develop the dorsal neck preparation while preserving the branches of the cervical plexus. Then develop the anterior neck preparation, exposing and preserving the superior thyroid artery and hypoglossal nerve. Neck dissection on the right side: This is carried out in the same way as on the left side, preserving the structures mentioned there. Overall removal of levels I - V on the left and II - IV and larger parts of V on the right. This is followed by the combined transoral-transcervical tumor resection: Firstly, external carotid artery exposure with removal of the branches. The external carotid artery is fused with the tumor in the cranial region or is very close to it. For this reason, the external carotid artery is resected above the exit of the lingual or facial artery and double ligated in each case. Subsequently, the lingual and facial arteries are also resected and cut. The superior thyroid artery remains. The pharyngeal tube is then removed from the spinal column. Furthermore, the tumor is now resected in a combined transoral and transcervical approach, controlling the course of the internal carotid artery, with a macroscopic safety margin of 2 cm on all sides. Resection extends cranially up to the tube, caudally beyond the hyoid bone to the piriform sinus entrance. Medially, half of the posterior wall is removed. Laterally, approx. 30% of the base of the tongue is resected. Marginal samples are taken from the hyoid bone area and from the caudal area (soft tissue and mucosa of the piriform sinus) and sent for frozen section diagnostics together with the thread-marked specimen. The specimen was tumor-free at the edges, slightly scarce caudally. Caudal margin samples from the base of the tongue and piriform sinus, including the soft tissue, also tumor-free. Thus R0 resection The defect is now covered using a radial flap from the left and the defect is covered on the left forearm: First measure the size of the defect. This is . -13 x 8 -9 cm. This defect size is marked on the forearm. The radial artery flap is incised in the typical manner. The radial artery is first clamped. After 10 min no special features, no drop in saturation. The radial artery is now removed and the flap is developed subfascially. Section towards the elbow. Dissection of the pedicle up to the elbow. Exposure of the radial artery up to the interosseous membrane and the accompanying vein up to the confluence. Exposure and dissection of the cephalic vein. ...... is placed on these vessels. Proximal puncture ligatures, especially in the radial artery. Subsequently, a full-thickness piece of skin of the appropriate size is removed in the groin area in a typical manner. This is followed by wound irrigation, hemostasis, layer-by-layer closure with insertion of a Redon drain. The full-thickness skin is sutured onto the defect and covers it completely. The remaining wound is primarily closed in layers up to the crook of the elbow. Mepilex dressing is then applied and a forearm splint is fitted. Radialis flap is now inserted into the defect and can cover it without tension. Suturing is performed with Vicryl 3.0 single button sutures. The vessels are then sutured. This is followed by an end-to-end anastomosis between the radial artery and the superior thyroid artery using 9.0 Ethilon. Then end-to-end anastomosis between the confluence of the radial vein + superior thyroid vein. Then end-to-side anastomosis between the cephalic vein and facial vein. In each case with 9.0 Ethilon. Overall good flow, good reflux. Vessels were constantly flushed with heparin. Patient received a perfusor with 500 E heparin/h after flap incision. Subsequent careful irrigation of the wound areas and hemostasis as well as layered wound closure on both sides of the neck with insertion of a Redon drain. After neck dissection, a tracheostomy was created. This is typically performed via a small Kocher collar incision. After exposing the infrahyoid muscles and splitting them, the thyroid isthmus is exposed. This is cut after clamping. Treatment with stitching sutures. Subsequent small visor-like, broadly pedunculated Björk flap. This is epithelized in the typical manner. Finally, after insertion of the laryngectomy tube, insertion of the size 8 tracheostomy tube. Completion of the procedure without complications. An enoral check shows good blood supply to the flap with a good aspect. The patient is admitted to the intensive care unit for postoperative monitoring. Please continue antibiotic treatment with Unacid, which was started intraoperatively, for 1 week. Nutrition via PEG for 10 days. After that, gruel swallow and, if necessary, build up diet. Continue heparin perfusor for 3 - 4 days at 500 E/h.