Induction of anesthesia and intubation by the anesthesia colleagues. Entry with the Kleinsasser tube and inspection of the hypopharynx and larynx. The tumor begins just below the tonsil lobe on the left side, extends caudally along the hypopharyngeal side wall, infiltrates the piriform sinus completely on the left side, infiltrates the postcricoid region on both sides and continues to grow into the esophageal entrance, infiltrating it caudally for approx. 2 cm. In addition, there is a demarcated oropharyngeal carcinoma on the left side, which exists on the side wall of the oropharynx independently of the hypopharyngeal carcinoma. Positioning of the patient. Sterile washing and draping, after injection and application of an apron flap in the usual manner. Start by releasing the larynx. To do this, the hyoid bone is released, then the infrahyal muscles are detached and the oblique laryngeal muscles are detached. Perform a tracheotomy below the cricoid cartilage and transfer to a laryngectomy tube. Detachment of the thyroid gland from the thyroid cartilage skeleton on both sides. This shows that the thyroid gland on the left side is also infiltrated. It is therefore first partially resected and later completely. The piriform sinus is then released on the right side; this is not possible on the left side. On the left side, it is already clear when the larynx is released that the tumor breaks outwards almost into the soft tissues of the neck. For this reason, a suture marker is placed at a questionable location and a representative sample is taken from the soft tissue, including a marginal sample. The marginal sample was tumor-free in the frozen section. Entering the pharynx from the right side. Disluxation of the epiglottis and resection of the mucosa and tumor with integration of the oropharyngeal carcinoma and resection of the esophageal inlet and removal of the larynx below the cricoid cartilage. The tumor is thread-marked in its entirety in the frozen section. All margins are free of tumor in the frozen section. In the area of the thyroid gland, the safety margin is less than 0.5 cm. Therefore, the tumor is resected again and the remaining thyroid gland is also removed and sent to the frozen section again, also thread-marked. Now everything is tumor-free. Measurement of the defect. The result was an 18 x 8 cm defect. A left lateral esophagomyotomy was performed very carefully and then the esophagus was incised in the middle to create a V-shaped entrance. The radialis flap will later be fitted into this V-shaped entrance. For this purpose, the radialis flap is also configured in a V-shape at the tip. Then lift the radialis graft. Lifting of the radialis flap by <CLINICIAN_NAME>: Drawing the flap boundaries in the presence of <CLINICIAN_NAME>. An 8 x 16 cm graft is drawn in. S-shaped incision along the skin incision in the area of the proximal forearm. Incision of the distal flap borders with separation of the skin and subcutaneous tissue. Dissection in the area of the venous confluence in the crook of the elbow and identification of the superficial and deep venous system. A pronounced cephalic vein can be seen, which is integrated into the radial flap margin, extending radially. After identification of the external radial nerve ramus, it can be safely spared. Ulnar skin incision down to the deep forearm fascia. Incision of the fascia and subfascial dissection of the flap from ulnar to radial. Care is taken to leave the peritendineum intact. Dissection up to the edge of the flexor carpi radialis muscle. Identification of the vascular pedicle and application of a vascular clamp for approx. 10 minutes: during this time a good perfusion signal is continuously measured. Decision to place the flap on the distal radial stump. Clamping and cutting of the radial artery and the vena comitans. Ligation of the stent. Dissection of the vascular pedicle, also from the depths, with constant blood supply using bipolar coagulation and vascular clips. The radial nerve can be safely identified and protected on the inside of the brachioradialis muscle. Insertion of a retractor between the extensor carpi radialis muscle and the brachioradialis muscle. Dissection in the area of the bifurcation of the brachioradial artery. Now pull in <CLINICIAN_NAME> and remove first the artery and then the veins. The flap can be lifted without complications. The radial artery as well as a deep and a superficial vein are available for anastomosis. This is followed by elevation of an equivalent area of split skin from the right thigh through <CLINICIAN_NAME> and <CLINICIAN_NAME>. Two-layer wound closure in the area of the s-shaped, proximal skin incision on the forearm. Incision of the split-thickness skin graft in the usual manner. Application of a wound dressing and a dorsal forearm splint. Application of a wrap bandage. Neck dissection is performed on both sides at the same time as flap lifting. To do this, expose the sternocleidomastoid muscle on the right side, the omohyoid muscle of the submandibular gland and the digastric muscle. Then free preparation of the cervical vascular sheath while preserving the facial vein and the superior thyroid artery and the hypoglossal nerve as well as the accessorius nerve and then release of the neck preparation II a to V a while preserving the plexus branches. Then switch to the opposite side. Here too, expose the sternocleidomastoid muscle, the omohyoid of the submandibular gland and the digastric muscle. Here too, free preparation of the internal jugular vein and the cervical vascular sheath. Then release the neck preparations II a to V a while protecting the plexus branches and the hypoglossal and accessory nerves. Deposition of the radialis graft by <CLINICIAN_NAME> and closure of the wound on the forearm with split skin from the right thigh by <CLINICIAN_NAME> and <CLINICIAN_NAME>. Reposition the patient and perform the arterial and venous anastomosis. The superior thyroid artery, the facial vein and an outlet from the facial vein are used for this. The cephalic vein and a vein of the deep venous system of the arm are anastomosed. The radialis graft is then inserted and reconstruction of the esophageal inlet begins. For this purpose, the V-shaped defect is reconstructed through the tip of the radialis flap, which is also V-shaped. To do this, sutures are placed and then the remaining graft is sutured in place. At the end, repositioning of the apron flap and suturing of the tracheostoma. A Provox prosthesis is not possible as the esophageal entrance was too deeply infiltrated and the anterior wall had to be reconstructed with the radial flap and this will also not be possible secondarily. At the end, insertion of two Redon drains and two-layer wound closure. The flap pedicle can be doubled in the middle of the neck. A skin monitor was not possible due to the short length of the stalk, but the flap can be checked via the Doppler and also at the base of the tongue via direct inspection. At the very end, the upper edge of the flap is punctured using a cannula. A good arterial blood return is seen immediately. The patient is ventilated and admitted to the intensive care unit. After consultation with the surgeon, please continue with the X-ray paps and antibiotics for at least 24 hours.