First induction of anesthesia by the anesthetist. Then bronchoscopic intubation by the anesthetist. This is very difficult as the large tumor masses almost completely obstruct the glottic plane. Ultimately, the patient can be intubated transnasally by bronchoscopy. Then we enter with the Kleinsasser tube and inspect the hypopharyngeal and laryngeal areas. Another detailed inspection of the tumor. As already described, the tumor begins at the lower tonsil pole, moves down the lateral pharyngeal wall and infiltrates the lateral and medial wall of the piriform sinus. However, the tip of the piriform sinus is free. Then infiltration of the postcricoid region and the pocket fold region in the right laryngeal region. Then placement of a feeding tube and sterile washing and draping. Start with the creation of an apron flap in the usual manner. Then perform a modified radical neck dissection on the right side. Exposure of the sternocleidomastoid muscle, the submandibular gland and the omohyoid muscle. Locating the accessorius nerve. This is difficult, as there are several large metastases in the area of level II a and b, which are first carefully detached. These can be dissected away from the jugular vein although they are directly attached to it. Dissection of the entire internal jugular vein. Removal of the remaining level II a and b. Levels III, IV and V are still covered with hard, rough metastases. These metastases are also located between the plexus branches and some plexus branches unfortunately have to be sacrificed in order to cleanly remove the metastases. The vagus nerve and border cord can be spared. The metastases themselves are directly adjacent to the internal and common carotid arteries, but can be easily dissected away from them. Then perform neck dissection level VI. Release the hyoid bone from the left side. Dissect the cervical vascular sheath on the right side of the larynx and hypopharynx. Skeletonization of the larynx. Separation of the entire laryngeal musculature. Exposure of the pharynx directly above the hyoid. Performing a pharyngotomy and extracting the epiglottis. Clamping of the epiglottis and cutting around the tumor with a sufficient safety distance, taking the hyoid bone with it. In the area of the pharyngeal side wall on the right, the tumor is resected, but with a very small safety margin, so a marginal sample is immediately taken again and sent for a frozen section. Fortunately, no tumor cells, no carcinoma in situ or higher-grade dysplasia. Further exploration of the larynx along the postcricoid region. First release of the thyroid gland and free preparation of the trachea. Entering the trachea and performing a tracheotomy. Performing a mucocutaneous anastomosis in the lower region. Re-intubation. Then return to the laryngeal preparation. The larynx is completely released along the postcricoid region and the cricoid cartilage. Separation of the larynx from the posterior wall of the trachea. The posterior wall of the trachea is cut upwards like a flap. The entire laryngeal preparation is sent to the frozen section marked with a suture. The pathologist is unable to detect carcinoma in situ, inverse carcinoma or high-grade dysplasia at the edges. Now the myotomy is performed. For this, the esophageal entrance and the esophagus are opened digitally and the constrictor muscles are cut with sharp scissors so that ultimately only the mucosa remains. The myotomy is performed posteromedially as usual. The lower attachments of the sternocleidomastoid muscle are then incised to create a flatter stoma. This is performed on both sides using the monopolar knife. After securing the R0 resection, elevation of the left forearm flap. Marking of the flap in a size of approx. 9 x 6 cm. Marking of a skin monitor. Subsequent resection of the flap from the ulnar side. Preparation of a subcutaneous bridge to the skin monitor on both sides. The incision is extended to the crook of the elbow. Then locate the superficial venous system. Integration into the subcutaneous bridge to the skin monitor. The flap is then lifted from the lateral side. Exposure of the lateral antebrachial cutaneous nerve. Distal clamping of the radial artery. Saturation always at 98 to 100 %. After approx. 15 minutes with good saturation, the artery is removed. This is ligated proximally distally with 4-0 Prolene. Then lift the flap subfascially. Smaller vessels are coagulated bipolar or treated with clips. Exposure and connection between the superficial and deep venous system in the antecubital region. Exposure of the radial artery. Clamping of the interosseous artery. If good saturation is maintained, closure of the. Interosseous artery using clips. Two good venous outlets from the cephalic vein can be visualized. Removal of the flap. Veins are ligated. The artery is closed in the entry area into the brachial artery using 6-0 Vascufil sutures. Then flush the flap with Ringer's solution. Before insertion of the flap, a left myotomy is performed in the typical manner. Complete transection of the muscle fibers. Esophageal wall is opened slightly distally at the entrance area to ensure greater passage. Provox prosthesis cannot be used primarily due to the overall situation. Flap is successively incorporated into the defect with 3-0 Vicryl single-button sutures. Tension-free closure. Stem is placed to the right. Conditioning of the radial artery and the superior thyroid artery. Suture with 8-0 Ethilon single-button sutures. Opening of the clamp, good arterial flow, good venous return. Two branches of the cephalic vein are selected for the anastomosis. The radial vein is clipped. One end of the cephalic vein is easily clipped to an outlet of the facial vein after selecting a 3-0 coupler. After opening the clamp, good venous return, positive smear phenomenon. The other part of the cephalic vein is coupled with the external jugular vein using a 3-0 coupler; here too, good venous return after opening the clamp, positive smear phenomenon. Subsequent careful irrigation of the wound area. Hemostasis. Wound closure in layers and placement of a Redon drain on each side, epithelialization of the tracheostoma and insertion of the skin monitor via a small transverse skin incision at the upper edge of the right apron incision. A 10 mm tracheostomy tube is then inserted and secured with sutures. In the thigh area, a piece of 0.8 mm split skin is removed in the corresponding size of the defect. Hydrogel dressing is applied to the thigh area. The forearm is primarily closed in the cranial area. In the caudal area, the defect is covered by suturing the removed split skin. Hydrogel-Mepilex dressing is then applied. Loose compresses are applied on top. Wrapping with absorbent cotton. Fitting of a Cramer splint in functional position. Wrap with elastic bandage. Arm always well saturated until the end. Completion of the procedure without complications. Patient goes to intensive care unit for postoperative monitoring. Insertion of Redon drains, one per side. Fixation of the Redon drain on the inside of the anastomosis, otherwise on the outside as usual. Two-layer wound closure and completion of the mucocutaneous anastomosis in the tracheostoma area. Insertion of a tracheal cannula. Fixation by suturing the tracheostomy tube and completion of the procedure without complications. Please continue antibiotics, which were started intraoperatively with Unacid, for at least 2-3 days. Feeding via the PEG tube that was placed during the last operation for at least 10 days, then gruel and, if necessary, diet build-up. Flap control via skin monitoring or using a Doppler probe for 5 days. Continue heparin perfusor 500 E/hour for 5 days. Total cT4 cN2b hypopharyngeal carcinoma with invasion of the right laryngeal skeleton. Discuss postoperative adjuvant radiotherapy versus radiochemotherapy according to the histologic findings.