First oropharyngoscopy/hypopharyngoscopy: The bulging tonsil on the right is visible, palpable induration in the pharyngeal wall. From....... Tonsil lobe up to the base of the tongue. Overall submucosally growing tumor. Incision is made in the area of the tonsillar lobe in the area of the induration. Several deep PEs here. These go to the frozen section. Invasive squamous cell carcinoma in the frozen section. Indication now given for further therapy. First PEG insertion: advancement of the endoscope into the stomach. There, after diaphanoscopy, problem-free insertion of a 9 mm stomach wall tube. Then sterile draping. Injection of a total of 10 ml xylocaine 1% with adrenaline. Tumor resection: Start enorally. The tumor is cut around at least all sides at a distance of approx. 1.5 cm, also towards the depth. Resection from the enoral side includes the base of the tongue almost to the middle, the entire tonsil lobe and large parts of the pharyngeal wall as well as the lateral wall of the oropharynx up to the transition to the posterior wall. In the hyoid region, the tumor has invaded the soft tissue here, including the external tongue muscles. It was therefore decided to proceed transorally at the same time. A modified radical neck dissection is therefore performed first: skin incision as for neck dissection, but slightly extended caudally in order to prepare a platysmal flap if necessary. Exposure of the anterior border of the sternocleidomastoid muscle. Dissection of the fat lymph node preparation. Exposure of the internal jugular vein, internal and external carotid artery, vagus nerve, hypoglossal nerve, accessorius nerve. Development of the dorsal neck preparation while sparing the branches of the cervical plexus and clearing out large parts of level V. Subsequent clearing out of the anterior neck preparation while exposing and preserving the superior thyroid artery and the hypoglossal nerve. Several right lymph node metastases were removed. Then dissection of the external carotid artery away from the pharyngeal wall. The external carotid artery is dissected cranially and caudally above the superior thyroid artery as it is directly adjacent to the part of the pharyngeal wall to be removed and several branches branch off in the direction of the tumor. The lingual artery is ligated and cut. Also the facial artery. The hypoglossal nerve is cut upwards. The entire pharyngeal wall is resected from the transoral or transcervical side to the hypopharyngeal entrance at the level of the superior cornu. All parts of the base of the tongue and the adjacent external tongue muscles are also resected. The submandibular gland can be preserved. The lingual nerve cannot be preserved. Marginal samples are now taken from the anterior soft palate to the glosso-alveolar junction and from the posterior palatal arch to the posterior pharyngeal wall, caudally from the base of the tongue and basally cranially from the area of the thyroid muscles and the adjacent fatty tissue and finally also from the soft tissue at the junction of the base of the tongue / hyoid bone / hypopharynx. These are sent for frozen section. In the Schenll section, all marginal samples are tumor-free. Now modified radical neck dissection on the left: This is performed in the same way as on the right side, exposing the structures already listed. Here, too, level II clearing and large sections of V. Here, too, the superior artery is dissected and preserved. Now mark a forearm flap on the left forearm corresponding to the defect size of approx. 10 x 7 cm. Curved skin incision from the elbow to the marked flap. Cut around the flap. Clamping of the radial artery. Oxygen saturation at 100 % for a prolonged period. Clamping of the radial artery, transection and closure using a puncture ligature. Lifting of the radial artery flap subfascially. Preservation of the main branch of the antebrachial cutaneous nerve. Dissection of the flap pedicle up to the elbow. Outlets are coagulated or closed by ligatures. In the elbow, the artery can be dissected and placed distal to the outlet of the interosseous artery, which is also shown. Closure by puncture ligation. ............. several outlets. Finally, exposure of a main vein. Deposition and ligation proximally. Irrigation of the vascular stumps with heparin. The entire wound area is now irrigated enorally and cervically with H2O2 and Ringer's solution. Careful hemostasis. The flap is inserted enorally through the defect. This can close the defect completely. The flap is successively sutured in place with Vicryl 3/0 single-button sutures. Complete closure. The flap pedicle is transferred from the right to the left side via a created tunnel. Here, the radial artery is sutured end-to-end to the superior thyroid artery with a 9/0 ethilon. The radial vein is sutured to the internal jugular vein using the end-to-side technique with Ethilon 9/0. TachoSil is applied to the anastomosis region. Repeated careful hemostasis and irrigation of the wound. Wound closure in layers with insertion of a Redon drain. The defect on the left forearm is covered with a full-thickness skin taken from the right groin. The full-thickness skin is thinned out before suturing. Several incisions are made to relieve pressure. The full-thickness skin can be sutured in well. The residual wound on the forearm is closed in layers. Groin is closed primarily with insertion of a Redon drain. Now tracheostoma creation: small Kocher collar incision, dissection through the subcutaneous tissue to the infrahyoid muscles. Splitting of the same. Exposure of the thyroid isthmus. Undercutting of the thyroid, clamping, severing and treatment with puncture ligatures. Finally, visualization of the trachea. Entering the 2nd/3rd intercartilaginous space. Creation of a Björk flap. Epithelization of the same. Insertion of a 9 mm tracheal cannula. Patient has received 2 x 3 g Unacid intraoperatively. Please continue this antibiotic treatment for 1 week. Feeding via PEG. After swallowing gruel on the 10th day, if necessary, diet build-up. Patient goes to the intensive care unit for postoperative monitoring. Overall, at least cT3 oropharyngeal carcinoma on the right from the tonsil lobe to the base of the tongue with soft tissue infiltration at the level of the hyoid bone. Lymphangiosis probable. Therefore discuss postoperative RCT.