First, pharyngoscopy and laryngoscopy again: The exophytic tumor is seen in the right hypopharyngeal region at the border to the oropharynx, beginning caudally, occupying the entire wall of the piriform sinus, with invasion into the right laryngeal skeleton. Tip of piriform sinus and esophageal entrance free. Base of tongue free. Therefore indication for the above-mentioned operation confirmed. The patient is now repositioned. Skin disinfection and injection of a total of 20 ml xylocaine 1% with adrenaline. Then start with the neck dissection modified radically on both sides: insertion of the apron flap in a typical subplatysmal manner up to beyond the hyoid bone and up to the submandibular gland on both sides. Then start with the right side: exposure of the sternocleidomastoid muscle, omohyoid muscle, digastric muscle. Exposure of the internal jugular vein, external jugular vein, internal carotid artery, external carotid artery, vagus nerve and hypoglossal nerve. Lymph node package from cranial to caudal must be detached from the internal jugular vein in case of strong adherence. It extends to caudal level Vb. Removal of the dorsal neck specimen, taking level V with it. Accessory nerve is exposed and preserved. The anterior neck specimen is then removed. Neck dissection on the left side: This is performed in the same way as on the right side. Overall evacuation level II to V as on the opposite side. Now laryngectomy with subtotal pharyngectomy: Prelaryngeal fatty tissue is also removed as part of the level VI neck dissection. Hyoid bone is detached from the suprahyoid musculature. Exposure of the pharyngeal wall. Pre-epiglottic fatty tissue is removed. Exposure of the superior cornu on both sides and dissection of the constrictor pharyngeal muscle, whereby this is mainly done on the left side. Dissection is omitted on the right side if there is a tumor. Dissection of the piriform sinus on the left. Caudal dissection of the thyroid gland on both sides. Tracheostomy and intubation. Insertion of laryngectomy tube. Subsequent paramedian insertion at epiglottis level. Dissection of lingual mucosa. Exposure of the epiglottis. The tumor is visible, which begins just below and medially in the epiglottis area. Tumor grows cranially in the direction of the tonsil lobe. Located approx. 1 cm away from the tumor, satellites can be seen in the caudal ................ area of the tonsillar lobe. These are cut around with a safety margin of 1 cm and removed. There are also satellites in the area of the posterior hypopharyngeal wall, so that the posterior hypopharyngeal wall must be subtotally removed. There is also a satellite focus in the arytenoid region on the left side. This results in a laryngectomy and a subtotal pharyngectomy. Laryngectomy specimen is thread-marked. Marginal samples are taken cranially laterally with marking towards the base of the tongue and cranially medially (marking of the tonsil lobe) as well as from the remaining hypopharyngeal wall up to the postcricoid area. Suture marking here as well. Small nodular infiltrations of an invasive tumor in the posterior hypopharyngeal wall in the specimen. Remaining margins and all marginal samples free. A resection in the postcricoid region and posterior hypopharyngeal wall as well as a margin specimen in this area is performed to be on the safe side. Tumor-free in the frozen section. It can now be definitively assumed that the resection is R0. This is followed by irrigation of the entire wound area. Due to the size of the defect after subtotal pharyngectomy and resection of the oropharynx up to the tonsil lobe and palatal arch, indication for defect coverage. The area in the right thigh was already sterilely draped at the time of insertion. The antero-lateral femoral flap is now removed: mark the spina and lateral edge of the patella. Locate the perforators along this line with the Doppler and mark them. These are located in a typical position or slightly cranial to it. The size of the flap was measured beforehand and is recorded in a length of 10 cm and a width of 4 to 8 mm according to the shape of the defect. Cut around the flap medially up to the fascia. Push the flap in the direction of the perforator. Identification of the rectus muscle and lateral vastus. Expose the perforators and the vascular pedicle. Cut around the flap caudally and laterally up to the fascia and dissect up to the septum. Expose the pedicle caudally and tie it under with ligatures. Successive development of the musculo-fasciocutaneous flap while carefully preserving the musculocutaneous perforators. If necessary, the vastus lateralis muscle is also removed. Finally, complete the cranial incision after the course of the perforators has been secured. Subsequent exposure of the pedicle. This consists of a strong ramus descendens and 2 strong accompanying veins. The artery is placed shortly before entering the profunda femoris artery. The 2nd artery is supplied with a stitching suture. 2 accompanying veins are placed before entering the profunda femoris vein or .........circumflexa iliaca and supplied with ligatures. The flap is flushed with heparin. Careful hemostasis is performed in the area of the thigh and the wound is closed in layers with the insertion of a Redon drain. The defect is then covered with a thigh flap: Fitting the flap into the defect. This fits without tension. Successive suturing using Vicryl 3/0 single button sutures. Flap can be sutured in without tension. Subsequent dissection of the vascular pedicle. The superior thyroid artery and the outlet of a superior thyroid vein from the internal jugular vein are dissected in good time. Subsequent conditioning and preparation of the flap vessels. Suture of the superior thyroid artery to the descending ramus with Ehtilon 8/0 using the end-to-end technique. After opening the clamp, good arterial flow and good venous return. Subsequent selection of the larger vein with better venous return. After measuring, selection of a coupler size 3 mm. Connection of the vessels using the coupler. Good venous return after opening the artery. Alignment test positive. The 2nd vein is closed using clips. Subsequent irrigation of the wound area. Careful hemostasis. Wound closure in layers and insertion of a Redon drain into each side of the neck and epithelialization of the tracheostoma. Marking of the vessels for Doppler monitoring. Insertion of a 10 mm tracheal cannula, which is fixed with sutures. Good Doppler signal at the end of the operation. Completion of the procedure without complications. Patient goes to the intensive care unit for monitoring. Please administer antibiotics with Unacid 3 x 3 g per day for one week. .............. via the inserted PEG for 10 days. After swallowing gruel, build up diet if necessary. Gastric tube should remain in place as a splint. Overall cT4 hypopharyngeal carcinoma with invasion into the larynx. Several satellites were resected. Overall, satellite-like multicentric growth. In addition, extensive lymph node metastasis, especially on the right. Postoperative RCT is certainly indicated.