First pharyngoscopy and laryngoscopy: The exophytic tumor is visible, which extends to the middle of the lateral wall of the left piriform sinus and extends medially to the arytenoid fold, but stops short of the arytenoid cartilage. The postcricoid area is not significantly involved. Tip of piriform sinus free macroscopically. Indication for surgery confirmed. The patient is now repositioned with all relevant surgical areas covered and disinfected. Firstly, insertion of the PEG: insertion of the flexible esophagoscope into the stomach, where no special features can be seen on rough inspection. After establishing the diaphanoscopy, insertion of a 15 mm abdominal wall tube without complications in a typical manner. Fixation to the abdominal wall in the typical manner. Subsequent insertion of an apron flap in the typical manner. Then start of radical neck dissection on the left: Large lymph node metastasis or the metastatic conglomerate, which has grown together with the sternocleidomastoid muscle and with the soft tissue in depth, is revealed. Successive dissection of the lymph node conglomerate. The internal and external carotid arteries can be dissected. The superior thyroid artery must be dissected. The facial vein must be removed, as well as signs of infiltration into the internal jugular vein, which must also be resected. The vagus nerve is also firmly attached to the tumor in the middle area and visibly infiltrated, therefore it is also resected in the middle area. The accessory nerve cannot be preserved either. The hypoglossal nerve can be dissected and preserved. Dissection of the specimen together with all affected lymph nodes. Some branches of the cervical plexus are also affected, which must also be resected. However, the majority of the plexus can be preserved. All in all, levels II to V are removed. The muscles are then removed from the hyoid bone. The hyoid bone is resected for a better overview. Entering the pharyngeal tube above the epiglottis. Exposure of the tumor. The carcinoma can be seen, which is cut around with a safety margin of 2 to 2 ˝ cm, caudally even up to 3 cm. The pharyngeal wall falls from the tonsil pole to the tip of the sinus and medially from the area of the vallecula to the posterior wall. The tumor preparation shows a tumor cone in the direction of the laryngeal skeleton, but this can be dissected off in healthy tissue. The arytenoid cartilage is partially de-epithelialized at the edge. Here the tumor is somewhat closer than at the other margins, therefore a separate marginal sample is taken from the vallecula over the arytenoid region down to the piriform sinus entrance. Likewise, a marginal sample is taken basally from the soft parts of the larynx where the tumor cone reached. The tumor specimen is also sent in thread-marked for frozen section. Both edge samples are healthy, in the area of the tumor preparation there is still small, infiltrating tumor growth towards the tip of the sinus, where the largest safety distance was. Therefore, another approx. 1 cm wide marginal sample is taken from this area, which is marked remote from the tumor. No more infiltrates in the frozen section. However, there is moderate dysplasia in the entire mucosal area at the edge. Overall, a satellite-like, wallpaper-like, mosaic-like growth can be assumed. Due to the locally existing R0 resection, however, no more resections. Excision biopsy of a calcified thyroid nodule from the left lobe. Now palpation of the thyroid nodule on the left side. This is approx. 1.5 cm in diameter. Hard consistency. The tumor is now removed from the left lobe of the thyroid gland via an incision. Then careful hemostasis and closure of the thyroid lobe with 2-0 Vicryl single button sutures. The neck is now dissected on the right side: after exposing the omohyoid, digastric and sternocleidomastoid muscles, levels II to IV and parts of V a and b are removed. The internal and external carotid arteries and outgoing arteries as well as the facial vein, internal jugular vein, vagus nerve, hypoglossal nerve and accessorius nerve and the branches of the cervical plexus are all exposed and preserved. Surgery was performed by <CLINICIAN_NAME>. Subsequent tracheostoma creation by <CLINICIAN_NAME>: After cutting the infrahyoid muscles, the thyroid isthmus is exposed. This is passed underneath, clamped off, severed and supplied in a typical manner using puncture ligatures. The trachea is then exposed. A modified, broadly pedicled Björk flap is created between the 2nd and 3rd cartilage. This is first epithelialized caudally. Subsequent reintubation. Tracheotomy was already performed before the final tumor resection. Then, after ensuring R0 resection, flap removal on the left forearm: Marking of the flap size, this is 10 x 8 cm. Marking of a skin monitor. Then first cut around the flap and the skin monitor as well as subcutaneous tissue subfascially from the ulna, then extend the incision into the crook of the elbow ..................................... Exposure of the superficial venous system with connection to the deep venous system. Subsequent incision of the flap from radial, subfascial. Exposure of the superficial cutaneous antebrachial nerve. Then exposure of the radial artery distally. Clamping of this. This is done for approx. 10 minutes, with stable saturation. Further removal of the flap in between. The radial artery is then removed. This is treated proximally and distally using 4-0 Prolene stitches. Lifting of the flap subfascially. Smaller arteries extending from the pedicle are clipped or bipolar coagulated. Dissection including the superficial venous system and the deep pedicle. A good but clearly medially located cephalic vein with 2 ends can be dissected in the antecubital fossa. The radial artery is dissected up to the entrance to the brachial artery. After clamping, the interosseous artery is left for a few minutes and closed with clips. The artery is then removed first. This is closed with 6-0 Vascufil sutures towards the brachial artery. Clamp and ligature the veins. The flap is then flushed with heparin solution. The arm is then closed in layers in the cranial area after careful hemostasis. A 0.7 to 0.8 mm thick split-thickness skin graft was obtained from the thigh, which is now successively incorporated into the forearm defect. Here complete closure. Sewing on swabs. Application of octenidine gel and application of cloud compresses. Then wrap with absorbent cotton. Fitting of a Kramer splint and fixation with an elastic bandage. Re-application of the arm. Saturation always close to or at 100% until the end of the operation. Subsequent insertion of the flap into the defect. The flap is inserted in such a way that the stalk on the opposite side can be anastomosed with the vessels. Successive suturing of the flap into the defect, partly with the sutures in place, using 3-0 Vicryl single-button sutures. The defect is closed without tension. The stalk is transferred to the opposite side. The superior thyroid artery is shown here. This is sutured to the radial artery after appropriate conditioning using 8-0 Vicryl single button sutures. Due to the different lumen, this must be done twice before a ......................... pulsation of the pedicle can be achieved. Then dissection of the 2 venous outlets from the superficial venous system and 2 outlets from the area of the facial vein. After conditioning, the first larger vein is anastomosed with the outgoing facial vein using a 4-0 coupler. The smaller outlet is also anastomosed with the smaller outlet from the stalk using a 2.5 mm coupler. Good venous return after opening the clamps in each case, positive smear phenomenon. After completion of the vascular anastomoses, strong pulse in the pedicle area and venous return. Subsequent positioning of the pedicle, careful irrigation and hemostasis. Wound closure by retraction of the apron flap. Caudal completion of the epithelialization of the stoma. Lateral cervical closure on the left by placing a Redon drainage, on the right by placing 2 flaps. Re-intubation and insertion of an 8 mm tracheostomy tube. This is fixed with sutures. At the end of the operation, arterial and venous flow could be observed very well with the Doppler. The skin monitor was sutured into the apron flap via a small incision in the ventral neck skin without tension and also showed a very good aspect. The procedure was completed without complications. Patient received Unacid 3 g preoperatively and again during the operation. Antibiotics should be continued for 1 week. Nutrition should be provided via the PEG tube already in place for at least 10 days. Then gruel should be swallowed and, if necessary, the diet should be built up. Heparin perfusor therapy started intraoperatively at 500 units per hour should be continued postoperatively for 5 days. Doppler control according to the scheme for 5 days incl. assessment of the skin monitor. Change the dressing on the forearm, if possible, only after 5 to 7 days. The hydrogel thigh bandage that was finally applied can be left in place for 3 to 4 days or changed depending on the findings. Please loosen the PEG the next day in the typical manner. Wait for the histology from the left lobe of the thyroid gland and then proceed according to the findings. Overall cT2 to 3 hypopharyngeal carcinoma on the left with infiltration up to the edge of the larynx. Therefore, the epiglottis margin, aryepiglottic fold, vallecula and parts of the laryngeal skeleton were also removed. Flap coverage by means of a radial flap. Extensive left cervical lymph node metastasis. Therefore, postoperative presentation in the interdisciplinary tumor conference on the question of postoperative radiochemotherapy. Due to the surgical measures, initiate swallowing rehabilitation at an early stage.