Induction of anesthesia and transnasal intubation by the anesthesia colleagues. Entry with the small bore tube and inspection of the hypopharynx and larynx. An exophytic tumor can be seen on the left side wall of the hypopharynx, extending to the entrance of the piriform sinus. The postcricoid region, the esophageal entrance and the tip of the left piriform sinus are free. The entire glottis is also free. Preoperatively, it was not possible to see the mobility of the left vocal fold due to tumor displacement. However, it is now apparent that the left arytenoid cartilage is not affected by the tumor. Due to the extension in the direction of the cervical sheath and the difficulty of adjustment, the decision was made to resect the tumor transcervically and, if necessary, cover it with a transplant. Injection of Ultracaine, then sterile washing and covering. Creation of an apron flap, then start with the neck dissection on the left side. Exposure of the sternocleidomastoid muscle, exposure of the omohyoid muscle, exposure of the submandibular gland. Level II shows a large conglomerate of lymph nodes which lies on the internal jugular vein. The internal jugular vein can be freed from the conglomerate. The facial vein is infiltrated and must be removed. Expose the hypoglossal nerve and the accessorius and release the remaining neck preparation level II a to V a while sparing the plexus branches. Now release the hyoid bone on the left side and remove the left half of the hyoid bone to gain direct access to the pharynx. Bimanual palpation from the transoral side and identification of the tumor. Release of the piriform sinus below the thyroid cartilage. Entering the pharynx above the tumor on the pharyngeal side wall. Inspection of the tumor. Now remove and cut around the tumor with a safety margin of 2 cm. The tumor can be retrieved enbloc and is placed completely on cork for frozen section. All edges as well as the wound bed are in sano in the frozen section. Due to the large defect, primary closure of the pharynx is no longer possible. Therefore, measurement of the defect and decision to cover the defect using a radialis graft. Start of elevation of the radialis graft by <CLINICIAN_NAME>. Marking of the graft 15 x 10 cm. Cutting around the skin island and opening the skin on the forearm. Exposure of the brachioradialis muscle. Exposure of the cephalic vein. <CLINICIAN_NAME> takes over the elevation of the radialis graft, dissects further and exposes the superficial ramus of the radial nerve, lifts the graft away from the tendon bed and first exposes the radial artery. There is good perfusion of the hand, which can also be verified by pulse oximetry. Further release of the graft and preparation of the vascular pedicle in the usual manner. The radial artery can be removed in the crook of the elbow, including the venous confluence with the possibility of venous connection of a superficial and a deep vein. Then usual closure of the forearm with split skin from the right thigh by <CLINICIAN_NAME> and <CLINICIAN_NAME>. The full-thickness skin was removed by <CLINICIAN_NAME> and <CLINICIAN_NAME>. Parallel to the elevation of the radialis graft, the neck dissection is performed on the right side by <CLINICIAN_NAME>. After the neck dissection on the left side, the patient is repositioned for the neck dissection on the right side. Incision already made as part of the previous dissection incisions. Locate the sternocleidomastoid muscle and dissect its anterior border in depth. Exposure of the anterior border up to level IV and up to level II while exposing and protecting the accessorius nerve. Exposure of the posterior abdomen of the digastric muscle. Dissection along the digastric muscle and exposure of the submandibular gland. Removal of the capsule in the caudal region. Exposure of the surface of the omohyoid muscle up to its cranial and caudal edge. Exposure of the cervical vascular sheath. Dissection of the same and removal of the soft tissue from medial to lateral and successive development of the neck preparation. Protection of the vagus nerve, the jugular vein and the common carotid artery. Exposure of the bifurcation. Dissection of external carotid artery branches for subsequent anastomosis. Successive development of the neck preparation and hemorrhage-free removal. Protection of the branches of the cervical plexus, which also represents the maximum posterior penetration depth of the neck dissection. At the posterior edge of the sternocleidomastoid, further dissection in depth and exposure of level V, where the neck preparation is also removed here. Neck dissection of the caudal level I b, II, III, IV and proportionally V of the right side. Irrigation with hydrogen peroxide and Ringer's solution. Finally, placement of a Redon drain. Repositioning of the patient for tracheostomy. Entry through the previously made apron incision and preparation of the cricoid cartilage. Exposure of the isthmus of the thyroid gland. Dissection and coagulation of the thyroid and subsequent transection. Individual craniocaudal veins are ligated. Exposure of the anterior wall of the trachea. Entering the trachea. Placement of tracheostomy sutures and, in the further course of the operation, finally reintubation with final placement of an 8-gauge tracheostomy tube. Suturing of the transplant by <CLINICIAN_NAME>. Multiple sutures must be submitted for this. The upper horn of the thyroid cartilage is resected to gain further access to the defect. First, an attempt is made to preserve the superior laryngeal nerve on the left side, but due to the thickness of the graft it is not possible to insert the entire graft between the pharynx and the superior laryngeal nerve, so this nerve must unfortunately be severed. Then complete suturing of the graft and positioning of the stalk on the right side. For this purpose, the superior thyroid artery is prepared for the arterial connection and the facial vein with an outlet for the venous connections. First start with the arterial anastomosis. Suture with 8.0 Ethilon. This reveals good pedicle perfusion and good venous return. Preparation of the vein. Unfortunately, the suction cup sucks in the pedicle and the entire arterial anastomosis is torn off. The arteries must therefore be shortened on both sides, prepared anew and anastomosed again. Only then can the two veins be couplers with a size 3.5 coupler. Now position the stem again. Fold back the apron flap. Incision of the tracheostoma and two-layer wound closure. A Redon drain was inserted on the left side and a flap on the right side. Continue antibiotics for at least 24 hours. Doppler control according to the usual procedure, a suture marker was placed on the neck and the flap can also be examined transorally. After receiving the histology, the patient is presented at the tumor conference to plan adjuvant therapy.