Patient with histologically confirmed hypopharyngeal carcinoma on the right. This is followed by a repeat panendoscopy preoperatively in domo after an external endoscopy. Tracheoscopy: Inconspicuous mucosal conditions subglottic to carina. Oro-hypopharyngoscopy: Inconspicuous mucosal conditions in the oropharynx, base of tongue and tonsil region. Inspection and palpation unremarkable. Hypopharynx left inconspicuous. From the end of the oropharynx to the beginning of the hypopharyngeal entrance on the left, an exophytic tumor is visible, which fills the entire piriform sinus from the lateral wall over the medial wall and over the postcricoid area to the opposite side. Esophageal entrance free. The above-mentioned operation is therefore confirmed, although the indication for flap plasty can probably only be definitively determined intraoperatively. PEG placement: Advancement of the flexible esophagoscope into the stomach. No evidence of tumor on gross examination, but conspicuous hyperplastic ......stone-like mucosal conditions in the cardia and corpus, antrum flatter. Check-up by an internist recommended. A 15 mm abdominal wall probe is then inserted in the typical manner after diaphanoscopy. Fixation to the abdominal wall. Subsequent repositioning for neck dissection on both sides, laryngectomy. Injection not possible. Sterile draping after skin disinfection. An apron flap is first created subplatysmally in the typical manner up to the level of the hyoid bone and submandibular gland, whereby the capsule should be included in the neck preparation. Subsequent neck dissection, initially on the right side: visualization of the sternocleidomastoid anterior border, visualization of the omohyoid muscle, digastric muscle. Exposure of the cervical vascular sheath. V. jugularis interna, facialis, A. carotis interna and externa as well as A. carotis communis. Exposure and preservation of vagus nerve, hypoglossal nerve, accessorius nerve. Subsequent removal of the medial neck preparation, initially preserving the superior thyroid artery. Then develop the dorsal neck specimen, exposing and preserving the branches of the cervical plexus. Careful hemostasis and irrigation with H202 and Ringer's solution. Overall evacuation level 2-5, whereby suspicious nodes were found in the cranial area level 2. Neck dissection on the left side: This is performed in the same way as on the right side. Level 2-5 clearance is also performed here, followed by laryngectomy and subtotal pharyngectomy. First, exposure and skeletonization of the hyoid bone and removal of the suprahyoid muscles. Removal of the prelaryngeal soft tissue, which is preserved as level 6. Subsequent dissection of the infrahyoid musculature from the hyoid bone and cutting caudally. On the left, problem-free skeletonization of the larynx by ...... of the superior chorda and dissection of the constrictor pharyngis muscle as well as dissection of the thyroid gland caudo-laterally. Dissection of the piriform sinus on this side. The superior thyroid artery is exposed and preserved. Subsequent dissection on the opposite side in the direction of the tumor. It becomes apparent that the tumor has most likely infiltrated the soft tissue next to the pharyngeal wall. Therefore, the upper pole of the thyroid gland is undercut and resected. In the area of the thyroid resection region, a suture is placed under and over the wall. The larynx is resected as a whole up to the thyroid gland, including the pharyngeal wall and upper thyroid pole. All soft tissue in the hyoid bone area is also resected pre-epiglottis. Now enter the left paramedian larynx. A tumor is revealed. This is resected successively with a safety margin of at least 1 to 1 ˝ cm in all directions. The entire pharyngeal wall on the right including the posterior wall is removed. A remnant of the posterior wall and the entire lateral piriform sinus wall remain. The entire postcricoid region must be resected in the direction of the esophageal opening, resulting in unfavorable and very narrow conditions. Before this, the thyroid isthmus, which is very thin, is cut through and the trachea is exposed and the trachea is opened in the 1st/2nd intercartilaginous space and sutured to the skin of the neck. The larynx with the entire pharyngeal wall on the right including the upper pole of the thyroid gland and the entire postcricoid region up to the esophageal entrance is then removed. The specimen is thread-marked and sent for frozen section examination. Carcinoma in situ on the left side in the frozen section. A 2-3 mm thick strip from the left resection margin is therefore cut again. Subsequently, another marginal sample approx. 2 mm wide is taken, which is also marked with a suture. The frozen section still shows mild to moderate dysplasia, no indication for further resection. Thus an overall R0 situation. What remains is a strip that is too narrow, barely 2-3 cm wide, particularly in the direction of the esophageal opening. Primary suturing does not seem sensible in terms of preserving the swallowing function. The decision was therefore made to cover the defect with a flap. Due to the patient's poor vascular situation, his secondary diseases and the favorable soft tissue conditions in the thoracic region, which allow a very thin flap to be elevated, the defect is covered using a pectoralis major flap from the right. First, the entire wound area was irrigated with H202 and Ringer's solution and the bleeding was carefully stopped. Then measure the size of the defect. Flap size is 10 x 8 cm. Corresponding trapezoidal shape in the direction of the esophageal opening. This is followed by elevation of the pectoralis major flap, provox creation and defect coverage in the pharyngeal region: after measuring the length of the pedicle, the defect is marked on the thoracic wall. Subfascial elevation of a bridge of the deltopectoral flap is then performed. Dissection under the pectoralis muscle and exposure of the vascular pedicle. Subsequently, successive incision of the skin island and development of the myocutaneous pectoralis major flap along the flap pedicle, taking into account the course of the vessel. Dissection up to the clavicle. Subsequent careful hemostasis in the thoracic region. Pull the pedicle through under the further deltopectoral skin bridge. Insertion of the skin island into the defect area. First myotomy and placement of the Provox prosthesis. For this purpose, the muscles on the left side in the area of the constrictor pharyngis muscle are successively cut with the scalpel and the scissors up to the mucosa. This allows better passage of the finger into the esophageal opening. Subsequent insertion of an 8.0 Provox prosthesis in a typical manner without complications. Insertion takes place 1-1.5 cm below the upper tracheal border. Then successive suturing of the pectoralis major flap into the defect, taking particular care to ensure that the passage into the upper esophagus is not too narrow. Tension-free suturing of the flap. Left lateral and cranial 2nd muscle suture over the flap. Muscle pedicle comes to lie over the suture on the right side. Careful hemostasis again. Irrigation with Ringer's solution. Skin closure in the neck area by placing the apron flap back with insertion of a Redon drainage in each side of the neck and epithelialization of the tracheostoma. Insertion of a 9 mm tracheal cannula. Now wound closure in the thorax area. It turns out that the skin can no longer be mobilized in such a way that primary closure is possible. Therefore covering in the thigh area. Split skin 0.5 mm thick is removed with the dermatome. Primary closure in the thoracic region as far as possible. A residual defect remains, which is covered with split skin. A total of 2 Redon drains are inserted in the axillary area and next to the flap pedicle. Mepilex with Chitogel is applied to the thoracic wound and thigh wound as a wound dressing. The procedure was completed without complications. Overall cT3-4 hypopharyngeal carcinoma with infiltration of the postcricoid area and larynx. At least cN2b status. Patient goes to intensive care unit for postoperative monitoring. Please continue antibiotics for a total of one week with Unacid 1.5 g 3 x/die. Feeding via inserted PEG for 10 days, then gruel and, if necessary, diet build-up. Inserted feeding tube should remain in place for splinting.