Dictation <CLINICIAN_NAME>: Pharyngoscopy/laryngoscopy: The exophytic tumor is visible, which completely fills the piriform sinus, infiltrates the larynx over a wide area, occupies almost the entire postcricoid region, extends into the piriform apex and also extends into the piriform sinus lateral wall with small flat extensions. Indication for surgery thus confirmed. Repositioning of the patient, skin disinfection and sterile draping of all surgical areas. First start with neck dissection and pharyngectomy: injection of a total of 10 ml Ultracaine with adrenaline into both sides of the neck along the apron incision. Then first subplatysmal dissection of the apron flap in the typical manner up to the level of the hyoid bone or submandibular gland. Then start with the neck dissection on the right: dissection of the fat-lymph node preparation of the sternocleidomastoid muscle. Exposure of digastric muscle, omohyoid muscle and infrahyoid muscles. Exposure of the cervical vascular sheath, internal/external carotid artery, internal jugular vein, vagus nerve, accessorius nerve, hypoglossal nerve. Clearing of neck levels II to V while preserving the branches of the cervical plexus. Glandula submandibularis remains in situ. Subsequent neck dissection on the left side: Here the procedure is the same, but only removal of levels II to IV and small parts of V. Then laryngectomy: Exposure of the hyoid bone. This is separated from the suprahyoid musculature. Removal of the preglottic fatty tissue with dissection up to the entrance to the pharynx. Expose the superior chorda. Dissection of the superior pharyngeal constrictor muscle. This is dissected to the right of the hyoid bone, but not resected further. The thyroid gland is dissected away caudolaterally on the right and the thyroid isthmus is separated after clamping and puncture ligation. Same procedure on the left. Dissection of the pharyngeal constrictor muscle and release of the piriform sinus. Also dissection of the thyroid gland caudolaterally. Then enter the epiglottis into the laryngeal or pharyngeal space. Exposure of the tumor. This is resected at a distance of 1 to 1.5 mm in the tumor border area, in the pharyngeal area. Microscopic inspection reveals extensions, the entire right pharyngeal wall falls just above the midline. On the left, the largest part of the pharynx can be preserved. In the area of the sinus tip, the defect is too large for a primary suture. The suture-marked preparation is sent to ....................... for frozen section histology. The tumor appears relatively close to the right side in the area of the transition from the postcricoid region to the laryngeal skeleton. Therefore, adjacent soft tissue in the form of fatty tissue, pharyngeal wall tissue and also thyroid tissue is resected from the upper pole and sent in as a right basal margin specimen. This was found to be tumor-free in the frozen section. Carcinoma in situ in the area of the entire right border. Also caudally at the transition to the esophagus. Therefore, a resection was performed using a mucosal strip several mm thick, certainly 5 to 7 mm thick, certainly 1 cm thick, from the area of the right pharyngeal wall down to the postcricoid area and the border to the pharyngeal area on the left. Then a marginal sample from the same area. This is now sent for frozen section histology. No more infiltrates here. Thus, apart from possible skip growth, the resection is R0. Myotomy of the constrictor pharyngis muscle, pars fundiformis on the left side slightly dorsally. This widens the relatively narrow esophageal opening. After the resection, a radial flap is always indicated to cover the defect. Irrigation of the entire wound area with hydrogen and Ringer's solution and careful hemostasis. Dictation <CLINICIAN_NAME>: Flap elevation of the radialis flap and coverage with split skin from the right thigh. After specifying a required graft of 11 x 9.5 cm by <CLINICIAN_NAME> with monitor island, the graft is first marked and aligned and then incised. Removal of the skin and preservation of the blood supply to the monitor. Due to the physiognomy of the patient, the width of the graft must be selected up to the extensor side. Subfascial release, careful radial exploration and preservation of the superficial ramus, radial nerve, but this must be neurolyzed over a long distance. This is ultimately successful. Maintenance of graft perfusion. Ulnar subfacial dissection, here careful dissection of the long superficial ulnar artery with clear kinking. Exposure of the radial artery. Clamping of the radial artery and later, after approx. 30 minutes without changing the good oxygen saturation of the hand, removal of the radial artery subfascially to develop the graft. Removal of the skin monitor while lifting a wide subfascial tissue anathema. Trace the graft or the vessels into the crook of the elbow, here the radial artery is isolated, the antosseous artery is relatively weak and is removed to obtain the pedicle length if the defect is extensive. There is a confluence of the superficial vein after elevation of the brachiocephalic vein with a wide bridge, which takes up the vein ............. of the radial artery and opens into a very strong cubital vein. In addition, 2 smaller venous outlets with drainage into the deep system are preserved. Careful hemostasis and, if the graft is vital on both sides, final placement of the graft after the supply and return vessels have been treated. The graft is then successively inserted into the pharyngeal defect using a special expansion suture in the area of the esophageal entrance. The operation is then handed over again. Incision of the radial flap: The flap measures 11 x 10 cm. It is sutured around the remaining remnants of the subtotally resected pharynx. This is done with 3-0 Vicryl single button sutures. In the area of the esophageal opening, incision and suturing of the triangular flap. Gastric tube already in place. A second row of sutures is made at the base of the tongue and on the sides. The infrahyoid musculature is sutured caudally over the flap connected to the esophagus, with the thyroid gland still lying over it. The flap is then connected to the vessels. The superior thyroid artery on the right is selected as well as a large outlet from the facial vein and a smaller outlet from a larger outgoing thyroid vein. After conditioning the vessels, suture the radial artery to the superior thyroid artery using 8-0 Vicryl single-button sutures. After opening the clamps, good arterial flow, good venous return. A larger outgoing vein from the facial vein is selected for the larger vein from the cephalic region. Anastomosis using a 4-0 coupler after measuring. After opening the clamps, good venous return, positive smear phenomenon. An outlet from the area of the deep venous system is connected to a small outlet from an outgoing thyroid vein, after measuring the width using a 2-0 coupler. Again, good venous return after opening the clamps. Positive smear phenomenon. Finally, careful hemostasis again. Any open veins, venous or arterial vessels are clipped or ligated. The skin monitor was sutured into the skin via a small median cranial incision, tension-free. Subsequent careful irrigation and hemostasis. Wound closure in layers with insertion of 2 Penrose drains on the right and one Redon drain on the left and epithelialization of the tracheostoma. Subsequently insertion of a 10 tracheal cannula, which is fixed with sutures. Completion of the procedure without complications. The patient is admitted to the interdisciplinary intensive care unit for postoperative monitoring. Flap control according to scheme by means of skin monitor control and Doppler sonography. Antibiotics continued for one week with Unacid. Feeding via the PEG tube for 10 days, then gruel and, if necessary, diet build-up. Overall cT4a hypopharyngeal carcinoma with infiltration of the larynx. Postoperative RT or RCT according to lymph node status.