First, pharyngoscopy again: The tumor is seen as already described, confirming the indication for surgery. PEG has already been placed. The first step is transoral tumor resection: the tumor is removed from all sides at a distance of at least 1.5 to 2 cm. Here, parts of the pharyngeal side wall on the left and the entire palatal arch as well as parts of the pharyngeal wall on the right up to the base of the tongue, which must be resected to about 20 to 30 %. The specimen is marked using sutures. In addition, a marginal specimen in the area of the palatal arch on the left up to the tonsil lobe on the left. Both specimens are sent for frozen section. Here still in situ spurs in the area of the palatal arch to the left tonsillar lobe. However, the marginal specimen is free. Nevertheless, another resection of a small strip from the area of the palatal arch to the lower resection margin, which is also included in this marginal specimen. This specimen is also thread-marked for the frozen section. No more tumor extensions here either. Thus now R0 resection. Now extensive hemostasis. Insertion of a hydrogen swab. Transfer to neck dissection, initially on the right: curved skin incision in the typical manner. Then expose the sternocleidomastoid muscle, the digastric muscle, the omohyoid muscle and the infrahyoid muscles. Subsequent visualization of the cervical vascular sheath, internal jugular vein, common carotid artery, external carotid artery, internal carotid artery. Visualization of the facial vein. Exposure of vagus nerve, accessorius nerve and hypoglossal nerve. Exposure and preservation of the superior thyroid artery. Successive creation of a neck dissection including nodes level II to V. Branches of the cervical plexus are preserved. Subsequent left neck dissection: This is performed in the same way as on the right side. Here, however, the neck dissection is limited to levels II to IV. Here too, careful hemostasis and irrigation with hydrogen and Ringer's solution. Subsequent tracheostoma creation: small Kocher collar incision. Subsequent dissection through subcutaneous tissue to the infrahyoid musculature. Splitting of these. Exposure of the thyroid isthmus. This is clamped off, severed and supplied by means of puncture ligatures. Exposure of the trachea. Creation of a broadly pedicled, modified Björk flap. Subsequent epithelialization of the Björk flap. Re-intubation and insertion of a size 8 tracheal cannula, which is fixed with sutures. Now remove the radial artery from the left forearm: Measure the required area of the flap, which is just under 15 x just under 7 cm. Mark the flap in the required size and orientation. Then cut around the flap, initially from the ulnar side. Extend the incision into the crook of the elbow. Exposure of the superficial venous system, which is included in the graft. Subsequent incision of the flap from the radial side. Exposure and preservation of the lateral antebrachial cutaneous nerve. Then exposure of the radial artery. This is first clamped for 15 to 20 minutes. Subsequently, the vascular pedicle is first exposed at the top. Exposure of the connection between the superficial and deep venous system. Then again locate the radial artery. Always good saturation of the hand with 100% saturation. Deposition of the radial artery. This is treated with 4-0 Prolene stitches. Anti-shear suture in the flap area. The flap is then lifted subfascially along the flap pedicle. Outgoing vessels are treated bipolar or with clips. Dissection along the pedicle up to the olecranon. Here, after clamping and with good saturation, the interosseous artery is removed. Two branches of the superficial venous system can be dissected as connecting vessels. The deep venous system consists of very small vessels, the confluence is very thin. Finally, the flap is placed on the brachial artery, here treated with a 6-0 Vascufil suture. Deposition at the confluence with a clip. Deposition at both ends of the superficial venous system and treatment with ligatures. Flushing of the flap with heparin. Subsequent insertion of the flap into the pharyngeal defect: First create a tunnel approx. 3 transverse fingers wide through the remaining pharyngeal muscles on the right side. Then pull the stalk through. Successive suturing of the flap into the defect, which begins at the base of the tongue or at the hypopharyngeal junction and extends to the opposite tonsil lobe. Tension-free suturing using 3-0 Vicryl single button sutures. Then vascular anastomoses in the neck area. Conditioning of the superior thyroid artery and the radial artery. These are connected using 8-0 Ethilon single-button sutures. After opening the clamps, good arterial flow and good venous return. The veins are conditioned. Both superficial veins are connected with 2 outlets from the facial artery. The 1st with a 3.0 mm coupler, the 2nd with a 2.0 mm coupler. Good venous return can be seen here in each case, positive smear phenomenon. Good aspect of the flap now also enoral. Subsequent careful hemostasis and irrigation of both sides of the neck. Wound closure in layers with insertion of a Redon drain in both sides of the neck, guided on the right. Now closure of the forearm defect: Split skin with a thickness of 0.7 to 0.8 mm is removed from the thigh area using a dermatome. This is successively incorporated into the forearm defect. The skin incision in the direction of the crook of the elbow is closed in layers. The arm is always well supplied with blood. Then bandage with hydrogel, Mepilex. Loose compresses placed on top. Wrap in absorbent cotton. Fitting of a Kramer splint, which is fixed with an elastic bandage. Finally, positioning of the arm. Completion of the procedure without complications. The patient is ventilated and transferred to the intensive care unit for monitoring. Please continue antibiotics with Unacid for 1 week. Heparin perfusor, which was started intraoperatively at 500 units per hour, should be continued for 5 days postoperatively. Feeding via the previously inserted PEG tube for 10 days, then gruel and, if necessary, diet build-up. Check the flap clinically and, if necessary, by Doppler according to the scheme. Wait for the final histology. Discussion of further procedure in the interdisciplinary tumor conference.