First re-inspect after positioning the patient. Inspection with the Kleinsasser tube. There is an exophytic mass in the area of the right tonsil lobe, passing over the soft palate to the parauvular area, filling the entire right tonsil lobe, transition to the posterior pharyngeal wall, the mass extends caudally in the area of the lateral pharyngeal wall to the hypopharyngeal level and ends just below the vallecula. The right edge of the epiglottis is just reached. Growth over the glossotonsillar groove towards the tongue, but no tongue infiltration here. The first step is transoral resection of the oral cavity, resection of the soft palate including the uvula and approximately half of the soft palate, resection of the entire tonsil lobe including the pharyngeal muscles down to the soft tissues of the neck. Resection and removal at the posterior floor of the mouth, taking the glossotonsillar groove with it. Covering of the soft palate and the posterior floor of the mouth with marginal samples, which are shown to be tumor-free in the frozen section diagnosis. Now reposition for neck dissection of the right side. A skin incision is made on the anterior edge of the sternocleidomastoid muscle, skin and subcutaneous tissue is cut, the platysma is cut, the external jugular vein and auricular nerve are exposed and preserved. Exposure of the sternocleidomastoid muscle, omohyoid muscle and digastric muscle. Exposure and preservation of the facial vein. Removal of the anterior neck preparation with careful protection and preservation of the superior thyroid artery, the hypoglossal nerve and the cervical vein. Free preparation of the internal jugular vein, exposure and preservation of the accessorius nerve, removal of the accessorius triangle and removal of level Va up to the border to Vb while carefully preserving the cervical plexus roots. Overall, no peritoneal growing metastases in the neck area. The glandula submandibularis is now extirpated and the neck dissection of neck level Ib is completed. Enter enorally via the posterior floor of the mouth. Then skeletonize the hyoid on the right side. Enter the pharynx into the vallecula cavity. Widen the pharyngotomy towards the pharyngeal side wall. Successive widening. Inclusion of the free epiglottis margin on the right, good overview of the tumor. Successive detachment, exposure and preservation of the superior laryngeal nerve. Exposure and skeletonization of the hypoglossal nerve and the lingual artery, both of which can be preserved. Exposure and preservation of the facial artery. Successive resection of the tumor with a safety margin, removal of the right lateral part of the base of the tongue to ensure the safety margin and removal of the tumor macroscopically in toto, which is thread-reinforced for definitive histology. Somewhat narrow conditions in the area of the posterior cranial pharyngeal wall on the specimen. A separate resection is therefore performed here. Similarly, if the macroscopic conditions are somewhat scarce in the direction of the vallecula, a resection is made here. Subsequently, the entire tumor is covered with marginal samples, which are completely tumor-free, with no evidence of higher-grade dysplasia; only in the area of the posterior edge of the tongue are there low to moderate-grade dysplasia. After discussing the case with the pathology department, a definitive marginal sample is taken. If the R0 situation is now present intraoperatively, the defect is measured. Performing defect reconstruction with microvascularly anastomosed ALT from the right after Doppler sonographic identification of the main perforator, here marking a graft measuring 14 x 7 cm in total. First medial incision. Exposure and identification of the rectus femoris muscle, subfascial release, exposure of the pedicle vessel. Exposure of the main perforator. Free preparation of the perforator. In case of musculocutaneous course, complete isolation of the perforator and overall configuration of the graft as a perforator flap. Partial preservation of the fascia lata around the perforator, otherwise lateral thinning of the flap. Isolation via the perforator to the vascular pedicle and placement of the excellent vital graft after isolation of the pedicle vessels. Final hemostasis. Insertion of a 10-gauge Redon drain and careful multi-layer wound closure with resection of excess skin. Neck dissection of the left side was performed at the same time. This also involved cutting through the skin and subcutaneous tissue and exposing the sternocleidomastoid and omohyoid muscles, releasing the submandibular gland and taking the caudal capsule with it. Exposure of the digastric muscle. Exposure and preservation of the facial vein, removal of the anterior neck preparation with preservation of the cervical artery, superior thyroid artery and hypoglossal nerve. Free dissection of the internal jugular vein, exposure and preservation of the accessorius nerve and, while preserving the accessorius triangle, limitation of the neck dissection in the direction of the level Va. Dissection up to the cervical plexus, which is carefully protected. Final wound irrigation and, if the wound is dry, insertion of a 10-gauge Redon drain and careful wound closure. The graft is then incorporated, combined transoral and transcervical graft suturing under difficult conditions with a complex defect. Overall, however, good fit and intact conditions on all sides. Conditioning of the superior thyroid artery, arterial anastomosis with 8-0 Ethilon, this is sufficient. Immediately good venous return with clearly leading strong vein. Conditioning of the facial vein, measurement of a coupler size 3.0 and performance of the venous anastomosis with the coupler system. Subsequent regular pedicle pulsation. Positive spreading phenomenon and vital graft enorally. No significant outflow via the second small vein, so that this is closed. Subsequent careful wound inspection and, if the wound is dry, insertion of a 10-gauge Redon drain and careful two-layer wound closure. The tracheotomy is then performed. Skin incision below the cricoid cartilage, separation of skin and subcutaneous tissue. Exposure and transection of the infrahyoid musculature. Exposure of the cricoid cartilage, exposure of the anterior surface of the trachea, transection of the thyroid isthmus. Insertion between the 1st and 2nd tracheal rings, creation of a broad-based Björk flap and incision of the tracheostoma in the typical manner. Subsequent problem-free transfer to a size 8 low cuff cannula, which is suture-fixed. The procedure was then completed with a vital graft and no indication of complications. Endoscopic PEG placement was performed at the beginning of the procedure. This was done with the gastroscope under laryngoscopic control. Easy pre-scanning into the stomach. With good diaphanoscopy, the stomach was punctured without any problems. The PEG tube is then inserted using the usual suture pull-through method. Note: The patient receives intraoperative intravenous antibiotics with Unacid 3 g, which should be continued for 24 hours postoperatively. Conclusion: Intraoperative R0 resected cT3 cN2b G2 cM0 oropharyngeal carcinoma on the right. If the graft and wound healed properly postoperatively, please perform an X-ray breischluck on the 10th postoperative day. Due to the size of the defect, a prolonged recovery of swallowing function can be expected. Adjuvant therapy is certainly necessary.