Initially start with PEG insertion: For this purpose, insertion with the gastroscope under laryngoscopic control. Easy pre-scanning into the stomach. If the diaphanoscopy is excellent, the stomach is punctured without any problems and the PEG tube is inserted using the usual thread pull-through method. Inspection of the oesophagus during reflection, inconspicuous conditions here. Now insertion with the small water tube, later supported with the TE blocker. A whitish, coarse, exophytic tumor of the right tonsil is seen, which clearly extends caudally, spreads to the posterior palatal arch in the lower half and leaves the tonsil lobe caudally and grows onto the oropharyngeal side wall up to the border of the hypopharyngeal side wall. Growth over the glossotonsillar groove circumscribed to the base of the tongue. Here also circumscribed infiltration of the base of the tongue. Posterior pharyngeal wall and soft palate are free. Now demonstration of findings on <CLINICIAN_NAME> and <CLINICIAN_NAME>. Due to the extent, confirmation of the indication for radial flap coverage, combined resection transorally and transcervically due to the growth. Start now with transoral resection: Initially transoral resection as for tumor TE, including the anterior palatal arch. Good overview. Exclusion of growth towards the pterygoid muscles. The posterior palatal arch can be well preserved cranially. Resection to parauvular. Here, however, no resection of the soft palate. Caudal removal of the posterior palatal arch. Now resection of the part of the glossotonsillar groove with complete removal of the glossotonsillar groove. Resection of the base of the tongue. Here, however, further resection of the base of the tongue transcervically for a better overview. Now carry out covering edge samples in the area of the soft palate, the posterior palatal arch and the buccal transition. These are completely tumor-free in the frozen section examination. Therefore, repositioning for neck dissection and completion of the tumor resection. Curved skin incision on the front edge of the sternocleidomastoid muscle on the right side after injection of xylocaine with adrenaline. Cut through the skin and subcutaneous tissue. Exposure and transection of the platysma and creation of a platysma flap. Exposure of the sternocleidomastoid muscle, the omohyoid muscle, the digastric muscle and the submandibular gland. Palpation of 2 coarse lymph nodes level II/III located in the area of the jugulofacial angle, certainly without infiltration of the sternocleidomastoid muscle. Clearing of the anterior neck preparation with preservation of the superior thyroid and the facial vein, which is very pronounced here. Free preparation of the internal jugular vein. Difficult preparation conditions in the area of the metastasis. Exposure of the accessorius nerve. Protection and preservation of the nerve. Difficult preparation conditions in the area of the metastases in the area of the internal jugular vein. Certainly no infiltration here, but vulnerable vascular conditions and two tears. Suture and ligature, but with preservation of continuity of the vein. Clearing of the accessorius triangle and level V with careful protection of the cervical plexus. Removal of the neck preparation en bloc. Now also evacuation of level Ib with infiltration of the glossotonsillar groove close to the posterior floor of the mouth. Subcapsular dissection of the submandibular gland. Extirpation of several lymph nodes measuring up to 1.5 cm. Removal of the gland. Final palpation. In free conditions, resection of the digastric muscle with planned flap coverage. Now orientate the digastric muscle at the posterior upper edge of the hyoid. Entering the oral cavity in the area of the posterior floor of the mouth. Widening of the pharyngotomy. Exposure of the resected edge of the tongue and the lateral wall of the pharynx. Now a good overview of the remaining tumor. Resection of the tumor in the area of the base of the tongue generously with circumscribed nodular infiltration in the area of the base of the tongue. Widening of the muscle cuff and later removal of a marginal sample. Resection of the tumor. Inspection. Findings demo to <CLINICIAN_NAME>. It can now be seen that the tumor in the area of the caudal pharyngeal wall is somewhat narrowly resected macroscopically on the specimen, as well as at the site in the area of the base of the tongue, where the safety margin was already widened during dissection. A generous resection is now taken at both sites together with the thread-marked main preparation and sent for frozen section diagnostics. Here, the tumor is classified as R0 on the specimen, but with narrow resection margins in the area of the caudal pharyngeal wall and in the area of the tongue. However, the resections here are completely tumor-free, meaning that the resection is R0 overall. Now measuring the graft. A 9 x 7 cm graft is later lifted, taking into account the resection area on the tongue and the resection of the glossotonsillar groove. Now continue to perform the neck dissection on the right side in parallel and remove the radialis graft in the area of the left forearm. First perform the neck dissection. Skin incision and cutting of skin and subcutaneous tissue. Dissection of the platysma. Exposure of the sternocleidomastoid muscle. Exposure of the external jugular vein and the auricular nerve. Exposure of the omohyoid muscle. Exposure of the submandibular gland. Exposure of the digastric muscle. Release of the anterior neck preparation with careful protection of the cervical artery of the superior thyroid artery and the facial vein. Exposure of the accessorius nerve. Free preparation of the internal jugular vein. Here, several lymph nodes that are macroscopically conspicuous in size and number, which are not yet primarily metastatic. Clearing of the accessorius triangle and level V with careful protection of the accessorius nerve and the cervical plexus branches. Final check. Irrigation of the wound. In dry conditions, insertion of a 10-gauge Redon drain and two-layer wound closure. Now to lift the radial implant. After applying the tourniquet and marking the graft, cut around it while lifting a skin monitor. Expose the cephalic vein to take the vein with you. Perform the Hayden maneuver and expose the superficial radial nerve ramus. Exposure of the distal vascular pedicle strictly subfascial to the dissection. Ligation of the pedicle. Further meticulous sufascial dissection with clipping of distal vessels close to the stalk. A relatively high brachial artery with a very strong ulnar artery can now be seen in the crook of the elbow. This is visualized and preserved. The proximal radial artery stump is relatively weak. Exposure of the outlet of the interosseous artery. This is preserved. Exposure of the venous bridge between the deep radial system and the cephalic vein, which is strongly pronounced. Separation of the veins while carefully preserving the bridge. Reopening of the tourniquet and minute hemostasis. Excellent flap vitality and after hemostasis removal of the graft after ligation of the radial artery with preservation of the interosseous artery and removal of the cephalic vein. In the meantime, the tracheotomy was also performed. Horizontal skin incision for this. Cut through the skin and subcutaneous tissue. Exposure of the infrahyoid musculature. Exposure of the cricoid cartilage. Exposure of the thyroid isthmus. Ligation of the isthmus and transection. Exposure of the anterior surface of the trachea. Insertion between the 2nd and 3rd tracheal ring. Creation of a broad-based pedicled Björk flap and insertion of the tracheostoma in the usual manner. Finally, easy transfer to an 8 mm tracheoflex cannula and suturing of the same. Now, first of all, placement of sutures transcervically in the area of the base of the tongue and in the area of the caudal pharyngeal wall. First incorporate the graft transorally. This works well. Good fit. Reconstruction of the anterior palatal arch, glossotonsillar groove and lateral pharyngeal wall. Further transzevical incorporation. Suturing in the area of the vallecula, the base of the tongue and the pharyngeal side wall under moderate tension. Now placement of the vascular pedicle. Suture the skin monitor caudally with a very long vascular pedicle. Exposure of the superior thyroid artery. The superior thyroid artery must now be shortened several times in order to achieve a thickness of approximately the same caliber. However, the vessel is very tortuous, and despite multiple positioning of the Acland clamps and the vascular pedicle, the angulation is unfavorable. Therefore extremely difficult anastomization conditions. Performing an anastomosis with 8.0 Ethilon. Finally, regular anastomization despite extremely difficult conditions. After reopening the clamps, regular venous return and good flap vitality. Now, after vascular preparation of the facial vein and the radial vein, perform the venous anastomosis with a size 4 coupler. This works well with a strong radial vessel and a very strong facial vein. Immediate good blood circulation and regular vitality. Overall, however, a tendency to displacement due to the long course of the vessel or stalk. Therefore careful placement. Careful two-layer wound closure. During the final check, a pale graft is noticed which does not bleed after puncture. Therefore the decision is made to reopen the neck in case of arterial problems. Visualization of the arterial anastomosis with macroscopically normal venous anastomosis. There is no longer a transmitted pulse. The artery is therefore removed. A thrombus is now visible. Despite removal of the thrombus and repeated flushing, there is no more arterial bleeding. Therefore, this vessel is removed and an arterial anastomosis is performed again. Careful dissection. The facial artery was already removed during tumor dissection. Now expose a somewhat cranially located vascular outlet, most likely corresponding to the ascending pharyngeal artery and macroscopically largely equivalent in caliber. Exposure of the vessel. Intermediate involvement of <CLINICIAN_NAME>. Now renewed vessel anastomization with 8.0 ethilon. Again, difficult suturing conditions due to the position of the vessel. Finally, however, regular flow, immediately good venous filling and regular flap vitality. Now, with regular vitality, wound closure in two layers. Final check and no further measures and transfer of the patient to the intensive care unit. A 10 x 6 cm full-thickness skin graft had already been removed from the right groin. Cutaneous preparation, mobilization of the subcutaneous tissue, careful two-layer wound closure after insertion of a 10 Redon drainage and finally careful incorporation of the full-thickness skin graft into the forearm. Two-layer wound closure and final application of a vacuum dressing and termination of the procedure at this point. Conclusion: Intraoperative cT3 cN2b oropharyngeal carcinoma on the left with intraoperative R0 resection. Defect coverage using a radialis graft with difficult anastomization conditions due to the vessel position and the length of the stalk. Meticulous flap control postoperatively. On the 8th postoperative day, an X-ray pumice should be taken. If the flap conditions are intact, the patient can then be gradually fed and decannulated, depending on the swallowing function. The patient received intraoperative intravenous antibiotics of Unacid and a single dose of 250 mg SDH. After receiving the histology, presentation at our interdisciplinary tumor conference to plan the adjuvant therapy.