First, pharyngoscopy again: The extensive tumor is visible, which runs from the right palatal arch over the tonsillar lobe into the base of the tongue. Growth in the posterior pharyngeal wall and there partly over the midline. Further smaller mucosal changes are clearly visible beyond the midline. Here mainly multicentric growth or satellite foci. Growth also up to the entrance of the hypopharynx. Growth into the base of the tongue and into the left vallecula or epiglottis. Therefore now at least cT3, more likely cT4 findings. Above mentioned OP confirmed. PEG placement: Entering the stomach with the flexible esophagoscope. After creating the diaphanoscopy, insertion of a 15 mm abdominal wall tube in a typical manner without complications. Fixation to the abdominal wall. Sterile draping of all surgical regions including the upper arm, thigh and pectoralis major area. Then start with transcervical, transoral resection: First insert the Mc Ivor blade. Tumor is cut around on all sides with a safety margin of at least 1.5 cm. Resection includes parts of the right palatal arch, entire lateral wall of the oropharynx, entire posterior wall of the oropharynx, glossoalveolar groove, from here the body of the tongue and almost half of the base of the tongue are resected. From enorally, marginal samples are taken from the palatal arch area, alveolar ridge, tongue body area, tongue base area and medial pharyngeal area. A marginal sample is also taken from the cranial, basal area. All marginal samples are tumor-free in the frozen section. The operation is continued from transcervical with neck dissection on the left: Submandibular section which is extended caudally along the sternocleidomastoid muscle. First exposure of the sternocleidomastoid muscle, exposure of the omohyoid muscle, digastric muscle. Exposure of the cervical vascular sheath, internal jugular vein, external jugular vein, internal carotid artery, external carotid artery. Exposure of vagus nerve, hypoglossal nerve, accessorius nerve. All structures are preserved. Visualization of vascular outlets from the. A. carotis externa, A. superior and lingualis as well as facialis can be visualized. Facialis is visualized up to the mandible and can be preserved. V. facialis and V. thyroidea superior are also visualized and preserved. Levels 1 to 5 are cleared in the typical manner, taking the submandibular gland with them. The digastric muscle and styloid and stylopharyngeal muscles are then resected. Tumor resection is now completed from the inside out, taking the entire pharyngeal wall with it and cutting around the entire tumor area. The tumor is pulled outwards and the resection is continued. This is followed by resection of 2/3 of the epiglottis and the left-sided vallecula area as well as almost the entire pre-epiglottic fatty tissue. The resection extends caudally to the hypopharyngeal entrance. A further satellite-like tumor can be seen further down, which indicates multicentric growth. Resection is therefore extended into the piriform sinus. Now take marginal samples from the caudal tongue base or vallecula area, caudal basal as well as a marginal sample from parapharyngeal tissue which is still located on the large vessels. The tumor is also sent in thread-marked to assess the basal margins or the caudal resection area in the area of the aryepiglottic fold and piriform sinus. Small focal or in situ infiltrations are still reported in the area of the vallecula, in the area of the piriform sinus and in the direction of the aryepiglottic fold. Vallecula is already secured by a marginal sample. This is followed by a further resection in the area of the entire aryepiglottic fold and piriform sinus. Subsequently, another margin sample, which is again thread-marked for frozen section. Finally, no more tumor infiltration can be seen here, so that ultimately a RO resection is surgically achieved. This is followed by the neck dissection on the right side. Here, level 2 to 5 is typically removed while preserving all structures. After measuring the defect, a corresponding, three-dimensional........ of the defect 12 x up to 10 cm resulting flap is marked in the area of the right thigh after marking several perforators around it. Then flap elevation on the right from the medial side, exposing the vascular pedicle. Then also from the lateral, subfascial side. The flap is lifted with the attached vastus lateralis muscle due to the perforators running through the muscle. Vascular pedicle is traced cranially. Small branches are ligated or clipped. The descending ramus or a common vein is placed cranially and supplied with 4 puncture ligatures. Due to the thick layer of fat, the deeper fatty tissue is removed and the flap is thinned. After hemostasis, the wound area in the thigh is treated in several layers with the insertion of 2 Redon drains. The thigh flap is then inserted into the defect and successively sutured in place without tension using 3.0 Vicryl single-button sutures, partly with the sutures in place. An anatomically correct, complete, tension-free closure is achieved. The vascular anastomosis is then performed. After conditioning the vessel ends, the superior thyroid artery and descending ramus are anastomosed using 8.0 Ethilon single-button sutures. After opening the clamp, good arterial flow and good venous return. Subsequent conditioning of the facial vein or the vein from the vascular pedicle. A size 3.0 coupler is selected. Coupler anastomosis without complications. After opening the clamp, good venous flow, positive smear phenomenon. This is followed by careful hemostasis of the neck on both sides and layered wound closure with insertion of a Redon drain on both sides. Particular care is taken on the left side to ensure that the vascular pedicle is not kinked, and the region for checking the vascular pedicle using Doppler is marked. During the procedure, a tracheostoma was created between the 2nd and 3rd tracheal cartilage using a small Kocher's collar incision in the typical manner. Epithelialization via a wide pedicled Björk flap in a typical manner. At the end of the operation, a tracheostomy tube with a core is inserted and sutured in place. Dressing on the right side. No dressing on the left side. Patient became dangerously catecholamine-dependent several times during the operation, so that a suprarenin perfusor also had to be connected. Due to the risk factors and the patient's relatively unstable circulatory situation, she was transferred to the interdisciplinary surgical intensive care unit. Heparin perfusor, which was started intraoperatively, should be continued at 500 E/hour for 5 days. Antibiotics started intraoperatively with Ciprobay should be continued for one week. Feeding via the inserted PEG tube for 10 days, then gruel and, if necessary, diet build-up. Control of the flap via enoral inspection and Doppler sonography at the marked neck site in a typical manner according to the scheme. Due to the extent of the tumor, at least one RT, if not an RCT, is certainly indicated postoperatively, provided this is possible for the patient.