First, pharyngoscopy and laryngoscopy again: The exophytic tumor is seen in the area of the hypopharyngeal side wall, passing over the anterior hypopharyngeal wall on the left to the postcricoid region and occupying it almost completely. The tumor also invades the left laryngeal skeleton via the arytenoid fold, thus confirming the indication for surgery. The patient is now repositioned: First neck dissection and tumor resection: creation of an apron flap in typical subplatysmal fashion. Then neck dissection on the right side: exposure of the digastric and omohyoid muscles. Dissection of the lymph node fat packet from the sternocleidomastoid muscle. Exposure of the cervical vascular sheath, internal jugular vein, common carotid artery. Internal carotid artery, external. Exposure of vagus nerve, hypoglossal nerve and accessorius nerve. Successive removal of the lymph nodes and fatty tissue from levels II-V, also by preserving branches of the cervical plexus. Neck dissection on the left side: This shows a conglomerate of cranial lymph nodes in level II, showing the omohyoid muscle and digastric muscle. The latter has grown together with the conglomerate and is also resected. Underlying the hypoglossal nerve. This runs through the middle of the lymph node conglomerate and must also be resected. Parts of the sternocleidomastoid muscle must also be resected in the cranial area. The internal jugular vein is also involved in the tumor process and must also be resected. It is exposed caudally and ligated twice. The lymph node conglomerate along the carotid artery and vagus nerve is then removed. Here, the mass must be dissected with some effort, particularly in the area of the bifurcation, but there is no tumor infiltration. Cranial exposure of the internal jugular vein and removal and double ligation of the vein also cranially in the vicinity of the jugular foramen. The accessorius nerve can be exposed and preserved here. Overall, level II-V evacuation as part of radical neck dissection. Subsequent tumor resection: First remove the level VI package, this is sent separately for histology. Then separation of the infrahyoid muscles from the hyoid bone. Subsequently detachment of the suprahyoid muscles from the hyoid bone. Exposure of the right superior cornu and separation of the piriform sinus. Separate the thyroid gland caudally and strike it caudo-laterally on both sides. On the left, the superior cornu is not released as it is located close to the tumor. Then enter the pharyngeal space above the level of the hyoid bone. Expose the tumor. The tumor is successively removed with a safety margin of at least 1.5 mm on all sides. This initially results in a partial pharyngectomy with laryngectomy. Laryngeal skeleton is released caudally with attached tumor and pharyngeal tube. Caudal creation of a tracheotomy and reintubation. Caudal suture of the trachea. The tumor preparation is then detached by cutting around a cranial tongue. The tumor specimen is marked with a suture. In addition, a caudal margin sample is taken and sent for frozen section. Unfortunately, carcinoma in situ infiltrate can still be seen in the left lateral, cranial and caudal tumor specimen. There is also carcinoma in situs in the area of the caudal margin sample. Therefore, margin samples are necessary at several locations. Extensive margin samples are taken approx. 1 cm wide caudally, laterally on the left and cranially. These are marked remote from the tumor and on the lateral suture. No more tumor infiltrates are visible here during the assessment. This ultimately results in a subtotal pharyngectomy. Due to the situation, defect coverage with a microvascular radial flap is now indicated. Provox prosthesis is not possible or sensible due to the overall situation and the proximity of the end of the defect to the potential Provox prosthesis site. However, a left myotomy has already been performed as part of the operation. The muscles of the cricopharyngeal muscle on the left side were completely severed over a length of 3-4 cm. Careful attention was paid to intact mucosa. This is followed by careful hemostasis and irrigation of the entire wound area. Now remove the left forearm flap: Marking of the defect size including skin monitor. Defect size 1.5 x 10 cm. Cut around the flap, initially ulnarly. Subsequently, dissection of the skin with some attached subcutaneous tissue and placement of a subcutaneous incision for skin monitoring. Extend the incision cranially to the crook of the elbow. Release of the skin monitor with subcutaneous tissue and superficial venous system. Release of the flap from radial, subfascial. Distal exposure of the radial artery. This is clamped for several times, here no changes in saturation, which is always 97-100 %. Subsequently, the radial artery is removed and treated cranially and caudally with 4-0 prolene sutures as a puncture. Successive elevation of the flap with deep pedicle, which was previously exposed under the brachioradialis muscle. Outgoing vessels are bipolarly coagulated and treated with clips. Exposure of a radial vein and cephalic vein through the antecubital fossa, which offers two outlets. Removal of the flap. The veins are ligated and the artery is treated with 6-0 Vascufil sutures. Spray the flap with heparin solution. Then successive insertion of the flap into the defect in the pharyngeal area. Incision of the skin at the esophageal entrance to improve the massage through the upper esophagus. Successive suturing of the flap with 3-0 or 4-0 Vicryl single-button sutures. This results in tension-free complete closure of the defect. The stalk is inserted cranially into the right side of the neck. Conditioning of the superior thyroid artery. Anastomosis with the conditioned radial artery using 8-0 Ethilon single-button sutures. After opening the clamps, good arterial flow, good venous return. V. radialis is anastomosed with an outlet from the A. facialis using a 2-0 coupler. Here too, good venous return after opening the clamp, positive smear phenomenon. A further vein which is branching off from the internal jugular vein is anastomosed with a branch from the cephalic vein, also using a 2.5 coupler. Again, after opening the clamp, good venous return, positive smear phenomenon. The remaining outlet from the cephalic vein is tilted close to the outlet. This is followed by irrigation of the entire wound area. Careful hemostasis. A Redon drain is inserted into each side of the neck on the right. The thyroid gland is adapted above the caudal part of the flap using 3-0 Vicryl sutures. Likewise the remaining infrahyoid muscles. Skin closure with suturing of the apron flap to the trachea and epithelialization of the tracheostoma. The skin monitor is sutured in place without tension via a small median incision. Good aspect. Tracheal cannula size 10 is placed and fixed with sutures. Closure of the forearm defect: approx. 0.7-0.8 mm thick split skin is removed from the thigh using the dermatome in a typical manner. The cranial parts of the wound on the forearm are sutured in layers. The defect is closed with the split skin, which is successively incorporated while protecting vascular and neuronal structures. Finally, a hydrogel-Mepilex dressing is applied and a loose compress bandage is placed over it and fixed with absorbent cotton. The arm is adjusted to a functional position on a Cramer splint and fixed with a flexible bandage. Loosening of the arm. Arm always well supplied with blood. Saturation between 95 and 100 %. The superficial wound area on the thigh is covered with a hydrocolloid dressing. Completion of the procedure without complications. Patient goes to the intensive care unit for postoperative monitoring. The antibiotic treatment that was started intraoperatively should be continued with Unacid for 2-3 days. Heparin perfusor with 500 E/h, which was started intraoperatively, should be continued postoperatively for at least 5 days. Flap control for at least 5 days according to the scheme via Doppler control and control of the skin monitor. Leave the intraoperatively inserted gastric tube in place, feed via the previously inserted PEG tube for at least 10 days, then swallow porridge and, if necessary, build up the diet. Overall cT4a hypopharyngeal carcinoma with invasion of the left laryngeal skeleton. Under subtotal pharyngectomy, defect coverage by means of microvascularly pedicled radial flap from the left side necessary. Overall, given the size of the tumor, postoperative free chemotherapy is indicated.