First intubation by the anesthesia colleagues, pharyngoscopy and laryngoscopy again, the tumor is seen growing on the left side pointedly in the direction of the vallecula and lower base of the tongue and as described in the direction of the supraglottic left, including the medial and lateral parts of the arytenoid fold. The upper parts of the hypopharynx on the left medial side are then also included laterally. Right piriform sinus free. Ingrowth into the pre-epiglottic soft tissues probable. Confirmation of the above-mentioned surgical indication. Initially PEG placement after suture insertion. With very good diaphanoscopy, this is successful without any problems. Repeated check of the Allen test. Even after several attempts, the Allen test on the left is positive. Therefore, Allen test on the right, which proves to be correct. Therefore no flap elevation of the radialis flap on the left, but on the right side. This is followed by skin disinfection of all relevant areas. Inject 10 ml into each side of the neck. Sterile draping of all relevant surgical areas. Start with elevation of the apron flap and neck dissection on both sides: (<CLINICIAN_NAME>, <CLINICIAN_NAME>). Elevation of the apron flap by <CLINICIAN_NAME> and <CLINICIAN_NAME> in the usual manner until the submandibular gland and hyoid are exposed. Neck dissectio Regio II to V left through <CLINICIAN_NAME>: Exposure of the anterior margin of the sternocleidomastoid muscle. Locate and protect the accessorius nerve. Tracing of the omohyoid muscle and the posterior digastric muscle. Exposure of the gl. submandibularis while preserving the facial vein. Retrograde dissection of the jugulofacial angle and exposure of the jugular vascular sheath. Exposure of the internal jugular vein and the ACC as well as the ACI/ACE and identification of the vagus nerve. This can also be preserved. Exposure and preservation of the plexus branches. Exposure and preservation of the hypoglossal nerve. Clearing of regions II-V on the left side. Final dissection medial to the ACC and start of release of the larynx and transfer to <CLINICIAN_NAME>. Right: Exposure of the anterior border of the sternocleidomastoid muscle. Locating and protecting the accessorius nerve. Tracing of the omohyoid muscle and the posterior digastric muscle. Exposure of the gl. submandibularis while preserving the facial vein. Retrograde dissection of the jugulofacial angle and exposure of the jugular vascular sheath. Exposure of the internal jugular vein and the ACC as well as the ACI/ACE and identification of the vagus nerve. This can also be preserved. Exposure and preservation of the plexus branches. Exposure and preservation of the hypoglossal nerve. There are suspicious lymph nodes in region II a and b on the right. These regions are successively removed. Regions III-V on the right side are also removed. A larger, deep-seated arterial vessel is ligated. Now dissection medial to the ACC and start to release the larynx. Subsequent tumor resection with laryngectomy, partial resection of the base of the tongue and partial resection of the pharynx on the left: First detachment of the suprahyoid musculature and the infrahyoid musculature from the hyoid bone. However, part of the suprahyoid musculature is left in place and included in the preparation. This is mainly central. Dissection of the soft tissues up to the supraglottic level is initially omitted. Instead, the infrahyoid musculature is separated and cut caudally. The lymph node fatty tissue of level VI was also dissected and also sent in as a specimen. Caudal transection of the thyroid isthmus. Ligation using stitching sutures. Lateral dissection. Opening of the trachea in the 1st/2nd interspace and then intubation. Insertion of a laryngectomy tube. The caudal trachea is fixed to the skin with 2 sutures. Then expose the superior cornu on both sides. Separation of the constrictor pharyngis from the cartilaginous skeleton. Dissect the piriform sinus more on the right than on the left. Then enter the pharynx on the right at the level of the epiglottis. Exposure of the tumor. Cut around the tumor macroscopically on all sides with a safety margin of at least 1.5 cm. The vallecula initially falls cranially. However, there is still some induration in the vallecula area. Therefore, an approx. 2-3 cm wide strip of mucosa with attached soft tissue is resected from the pharyngeal margin on the right over the base of the tongue to the pharyngeal margin on the left. The sutures are placed close to the tumor and the specimen should be examined away from the tumor. The larynx is developed further caudally while protecting the pharyngeal mucosa as much as possible. Dissection of the distal hypopharyngeal and esophageal entrance. Subsequent removal of the larynx, whereby the trachea is preserved up to the lower edge of the cricoid cartilage in a tongue for suturing. In the cranial pharyngeal region, a marginal sample several mm thick is taken from both the right and left side up to half of the pharynx caudally. These, as well as the entire specimen, are thread-marked for the frozen section margin examination. No evidence of tumor infiltrates in the frozen section in any of the marginal samples. Thus R0 situation. Careful hemostasis and irrigation. Subsequent insertion of a size 10 Provox prosthesis in the typical manner. Then myotomy, whereby the muscles of the constrictor pharyngis are severed on the left side. This significantly improves passage in the esophageal opening. Then elevation of the radial lobe: (<CLINICIAN_NAME>): After rechecking the negative Allen test on the right side, draw in the landmarks. Skin incision and dissection of the subcutaneous fatty tissue. This is very thin, so care is taken to leave enough subcutaneous fatty tissue on the skin to avoid necrosis. Dissection of the cephalic vein and exploration of the venous star. Expose and expose the pedicle. Cut around the ulnar side of the 8x8cm flap according to the frozen section result. Palpation of the ulnar artery in depth. Incision of the radial side and radial dissection of the cephalic vein in order to integrate it into the flap. Locate the radial artery distally. Preservation of both branches of the superficial radial nerve. Placement of the graft and irrigation with heparin. At the same time, large areas of split skin are removed from the right thigh in the usual manner. Application of sterile wound dressing in the area of the donor site. Two-layer wound closure in the area of the proximal forearm and suturing of the split skin with relief incisions. Application of a sterile wound dressing and a forearm splint. Completion of the graft lift without complications. Subsequent placement of the right arm. Then insertion of the flap into the defect and vascular anastomosis. Flap is successively sutured into the defect without tension using 4-0 Vicryl single-button sutures. Flap pedicle is transferred to the right side of the neck. Conditioning of the radial artery and a large cephalic vein as well as a small radial vein. Conditioning of the facial vein and a small thyroid vein as well as the facial artery, which is dissected. The facial artery is first anastomosed using 8-0 Ethilon single-button sutures. After opening the clamps, good arterial flow, good venous return. Then anastomosis of the cephalic vein with an outlet of the facial vein using a 3.0 coupler. Then anastomosis of the small V. radialis with the small V. thyroidea media using coupler 1.5. In each case after opening the clamps, good return flow, positive smear phenomenon. Attempt to fix a Doppler flow system to the vein, which was not successful despite several attempts, as the signal was too uncertain. The ultrasound probe is then discarded. Stem is adjusted to prevent kinking. Irrigation of the entire area and careful hemostasis. Subsequent layer-by-layer wound closure with placement of 2 flaps on the right and a Redon drainage on the left and epithelialization of the tracheostoma. Subsequently insertion of a 10 mm tracheostomy tube. The procedure was completed without complications. Patient goes to the intensive care unit for monitoring. Here, please monitor the flap closely clinically by inspecting the flap via the pharynx or by Doppler sonography at the marked site for 5 days. Please continue antibiotics that were started intraoperatively for one week. Feeding via the inserted PEG tube. On the 10th to 12th day, swallow porridge and then build up the diet if necessary. Overall cT4a supraglottic laryngeal carcinoma with infiltration of the vallecula and caudal base of the tongue as well as part of the medial hypopharynx on the left. Suspicious lymph nodes on both sides. Please present postoperatively after receiving the final histology in the interdisciplinary tumor conference.