After induction of anesthesia and intubation by the anesthesia colleagues, a new pharyngo-laryngoscopy is performed to search for the primary ear again. Entry with the Kleinsasser tube under dental protection and inspection of the inconspicuous oral vestibule. Inspection of the oral cavity, which, including the floor of the mouth, tongue and soft palate, is free on inspection and palpation. Inconspicuous oropharynx on the right side. The entire hypopharynx up to the entrance to the esophagus is also clear, inconspicuous endolarynx. In the area of the left piriform sinus, an exophytic, papillomatous tumor is now visible, which grows like a lawn in the piriform sinus and almost completely fills the piriform sinus from the lateral wall to the medial side. The esophageal entrance is certainly free. It can be seen that the tumor extends laterally to the left arytenoid via the medial piriform sinus wall, as well as to the postcricoid region, but here it is superficial on all sides, with no evidence of deep infiltration. Multiple deep biopsies were taken to confirm the diagnosis. The frozen section diagnosis now shows an invasive squamous cell carcinoma matching the already confirmed lymph node metastasis. Overall, however, the flat tumor is cT3 due to its size of over 4 cm. After hemostasis using suprarenal intubation, a PEG tube was inserted. For this, insertion with the gastroscope. Under laryngoscopic control, easy advancement into the stomach. Now, with good diaphanoscopy, problem-free puncture of the stomach and insertion of the PEG tube using the usual thread pull-through method. The esophagus is inconspicuous on reflection. The patient was then repositioned and prepared for neck dissection on the left. Here a barely displaceable mass approx. 7 x 5 cm is seen, which sonographically is also clearly at least adjacent to the carotid artery. Palpation revealed clear infiltration of the sternocleidomastoid muscle. Make a curved skin incision at the anterior edge of the sternocleidomastoid muscle, taking the scar of the trial excision with it. Spindle-shaped excision of the scar. By excising the scar, the tumorous mass can be accessed directly. This is clearly a soft tissue metastasis without only a capsular structure, therefore extensive excision of the scar. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle and exposure of the digastric muscle. This can just be separated from the soft tissue metastasis. Gross infiltration of the surrounding tissue. Therefore caudal separation of the sternocleidomastoid muscle, also safe infiltration of the accessorius nerve. Partial approach of the metastasis to the omohyoid muscle, which is also taken along. Detachment of the thyroid gland, which is not infiltrated. Now visualization of the internal jugular vein, which is thrombosed here and clearly infiltrated caudally. Caudal visualization of the internal jugular vein, also showing clear signs of thrombosis and a very slender vessel. Visualization of the common carotid artery and the vagus nerve. Separation of the internal jugular vein, caudal and cranial after ligation and repositioning. Exposure and release of the submandibular gland, which is exposed. Anterior exposure of the hypoglossal nerve, which is also free here, overall difficult preparation conditions. Difficult resection conditions due to the partly diffusely growing soft tissue metastasis. Now dissect the common carotid artery, which is free. Exposure of the bulb, exposure of the exit of the internal and external carotid artery. After the exit of the external carotid artery, infiltration of the superior thyroid artery is seen. Later there is also infiltration of the lingual artery. Further dissection and retrograde tracing of the hypoglossal nerve also revealed a clear infiltration of the hypoglossal nerve. This is therefore also resected. Cranially, the external carotid artery is also thickened, so that the external carotid artery is resected approx. 2 cm from the exit after puncture and multiple ligation if its exit is safely infiltrated. Now good isolation of the internal carotid artery, which can be easily released after careful dissection, no infiltration here, so that macroscopic in sano resection is performed after removal of the metastasis from level 5 with partial infiltration of the cervical plexus and the surrounding musculature. When the right side wall of the pharynx is removed, a spontaneous perforation occurs in the direction of the pharynx with direct contact to the primaries, so it can be assumed that the metastasis is growing per continuitatem. Finally, clearing of levels Va and Vb. Ligation of the caudal level Vb without evidence of lymph flow. The jugular vein had already been removed previously, but its drainage area was preserved. Now turn to tumor resection. First, after dissection of the paralaryngeal muscles, expose the thyroid cartilage horn, push off the perichondrium, remove the lateral thyroid cartilage, carefully detach the hypoharyngeal mucosa. Now enter above the spontaneous pharyngeal opening, widen the pharyngotomy. Now a good overview. As described above, the tumor appears like a turf and very superficial in the extensions. Macroscopically inconspicuous. Therefore, first resection of the macroscopically altered tissue. The resection extends over the entire piriform sinus up to the arytenoid as well as approx. 1/3 of the postcricoid region. Starting from the left arytenoid, it can be seen that a tumor turf also extends to the aryepiglottic fold and reaches up to the edge of the pharyngoepiglottic fold, completely detaching the altered area. Due to the already spontaneous perforation of the tumor, the tumor was resected in parts, certainly no deep infiltration. Completely covering the tumor, the removal of completely imaging margin samples is now carried out. In the area of the medial piriform sinus wall, there is still margin-forming CIS with otherwise in sano resection of the invasive carcinoma. Therefore, a resection is performed first and then a final margin sample is taken, which shows moderate dysplasia in the frozen section diagnosis without evidence of CIS or invasive carcinoma. Therefore, an R0 resection can be assumed here. This results in a defect that includes the entire piriform sinus, including the medial wall up to the postcricoid region. The endolarynx and the arytenoid joint itself were not altered. In addition, the left aryepiglottic fold was resected as well as the lateral edge of the epiglottis up to the vallecula. A total defect measuring approx. 10 x 5 cm is now measured, readaptation of previously released postcricoid mucosa. Due to the defect and the extensive cervical metastasis, there is now an indication for defect reconstruction. Therefore, the tracheotomy, right-sided neck dissection and ALT graft harvesting from the right thigh are now performed in parallel. First the tracheotomy. To do this, make a skin incision approx. 1 cm below the cricoid cartilage, cut through the skin and subcutaneous tissue. Expose and ligate both anterior jugular veins, expose the infrahyoid muscles, enter the linea alba. Exposure of the cricoid cartilage, exposure of the anterior surface of the trachea. Identification and clamping of the thyroid isthmus. Transection and puncture ligation. After exposing the anterior surface of the trachea, insertion between the 2nd and 3rd tracheal ring: creation of a broad-based Björk flap and insertion of the tracheostoma. Subsequent intubation, initially onto a Woodbridge tube, later onto an 8 mm Rügheimer cannula, which is suture-fixed. Now for neck dissection of the right side of the neck. To do this, make a curved skin incision on the anterior edge of the sternocleidomastoid muscle. Cut through the skin and subcutaneous tissue. Exposure of the sternocleidomastoid muscle, omohyoid muscle and digastric muscle. Exposure of the submandibular gland, exposure of the accessorius nerve and free dissection of the internal jugular vein with careful protection and the strong anterior branches of the veins, which end in a type of facial venous plexus. Exposure and preservation of the hypoglossal nerve, cervical artery and superior thyroid artery. Clearing of the accessorius triangle and level 5 with careful protection of the cervical plexus branches. Subsequent vessel preparation. An antero-lateral transfemoral graft is then harvested from the right side; after marking the landmarks, two strong main perforators and a secondary perforator are identified by Doppler sonography. Removal of a 16 x 5 cm graft to obtain a skin monitor. Initial medial skin incision, cutting through skin and subcutaneous tissue. Expose and secure the rectus femoris muscle. Strictly subfascial preparation, identification of the ramus descendens, the lateral circumflex artery. After visualization of the anatomy, it is now apparent that the ramus descendens provides an intramuscular perforator and the ramus obliquus a fasciocutaneous perforator. Careful dissection of both pedicle vessels. Despite dissection up to the groin, there is no common arterial confluence. Therefore, initially leave both vessel preparations and primarily the ramus descendens completely cut around the graft, distal ligation of the vascular pedicle. Inclusion of the fascia lata, caudal fasciocutaneous elevation of the graft in the area of the caudal perforator. Inclusion of a muscle cuff to protect the perforators. Cranial fasciocutaneous elevation again. A regular flap vitality can be seen on all sides. Now, with a long but slender vessel of the descending branch, the cranial perforator is clamped off, and even after waiting there is no change in perfusion and therefore restriction to the caudal main perforator. Dissection of the long artery and the vein after confluence and removal of the graft with normal vitality. Careful wound inspection and, if conditions are dry, insertion of a Redon drain and careful and strong two-layer wound closure. The graft is now inserted and a patch measuring approx. 10 x 5 cm is inserted into the pharyngeal defect. Overall good fit. Deepithelialization of the remaining graft, leaving an area of skin measuring approx. 3 x 3 cm in the tip of the flap. This is later sutured into the cervical skin for monitoring. After complete and sufficient suturing, there is now no possibility of left-sided anastomosis due to the narrow vessels, therefore prelaryngeal tunneling, creation of a wide tunnel of approx. 6 cm. After fixation of the fascia lata and the muscle cuff, the vessels are moved to the right side of the neck under tension-free conditions. Good positioning here. Conditioning of the flap vessels, conditioning of the superior thyroid artery, placement of the superior thyroid artery after clipping of the part. Good flow conditions here and subsequent performance of the vascular anastomosis with 8.0 Ethilon, this succeeds without any problems despite a clear caliber advantage on the part of the superior thyroid artery, followed immediately by good venous return. Conditioning of an anterior internal jugular vein, measurement of a size 3.5 coupler, problem-free performance of the venous anastomosis with the coupler, immediate regular flow with good flap perfusion. Careful positioning of the stalk and, if flap vitality is normal, cervical insertion of a 10-gauge Redon drain and careful two-layer wound closure on the left side using the raised skin monitor. Final laryngoscopic check. The graft is intact with normal vitality as far as can be assessed here. Regular vitality in the area of the skin monitor and termination of the procedure at this point. Note: Due to an intraoperative drop in oxygen saturation, the recovery process was monitored in the operating theater. A detailed clinical, neurological diagnosis reveals an oriented and responsive patient with lateral motor function and reflexes as well as lateral pupils with regular light reflexes. Postoperative neurological monitoring of the patient and, if neurological deficits occur, neurological consultation with imaging. Conclusion: Intraoperative R0 resected cT3 cN3 G3 hypopharyngeal carcinoma on the left. The defect was reconstructed using an anterolateral transfemoral graft from the right with right cervical vascular anastomosis. Please monitor the flap via the sutured skin island and via enoral inspection with the patient awake. If possible, please leave the tracheal cannula in place for at least 5-7 days postoperatively due to the prelaryngeal vascular pedicle and leave the Redon drains in place for at least 3-4 days postoperatively. If flap vitality is normal, perform an X-ray pre-swallow on the 10th postoperative day. Due to the extent of the resection, a prolonged recovery of swallowing function can be expected.