First perform a panendoscopy, for this purpose first perform a rigid tracheoscopy under laryngoscopic control, this is difficult to do in very rigid conditions and restricted mouth opening, but can be performed. Here, the trachea is clear, with a whitish mucosal overlay on the right side of the glottis in the area of the anterior commissure. Otherwise unremarkable conditions. Intubation transnasally without any problems. Flexible esophagogastroscopy was then performed first. The gastroscope was inserted and the laryngoscope was checked and there were no problems with the esophagoscopy up to the stomach. Inconspicuous conditions here. Puncture of the stomach with excellent diaphanoscopy and insertion of the PEG using the usual thread pull-through method. Inspection of the esophagus on retraction, inconspicuous findings here. Now entering with the Kleinsasser tube. An exophytic tumor of the left oropharynx is seen on the left side, passing over to the soft palate to the left parauvular region. Significant lateral growth towards the mandibular branch and towards the soft tissues of the neck, the glossotonsillar groove and a circumscribed part of the base of the tongue are also affected. An extension towards the posterior pharyngeal wall and hypopharynx. Otherwise, apart from the lesion in the area of the right vocal fold described above, the findings were unremarkable. A sample is now taken from the anterior right vocal fold, which shows a polypoid mucosa in the frozen section without dysplasia or evidence of malignancy. Therefore, no further measures are taken here. Now start with the enoral resection of the tumor. For this purpose, resection of the tumor including about 2/3 of the soft palate, resection with posterior palatal arch, resection border reaching anteriorly to buccally. A clear growth towards the alveolar ridge and the soft tissues of the neck can be seen in the deep area. The tumor is now detached in the direction of the alveolar ridge. The alveolar ridge itself is not infiltrated. Push off the tumor here, laterally dissect the tumor, taking the masticatory muscles with it down to the pterygoid process. Further dissection with careful palpation of the cervical vascular sheath, removal of the tumor is very difficult with limited mouth opening in the area of the glossotonsillar junction and the base of the tongue. In this case, about 1/3 of the base of the tongue is removed. Further resection is carried out transcervically. Mucosal samples are taken covering the soft palate, buccal alveolar ridge, tongue and posterior pharyngeal wall, all of which are diagnosed as tumor-free in the frozen section. In the area of the pterygoid muscles and the lateral wall, multiple biopsies are taken in the area of the wound bed for screening purposes. All of these were later also assessed as tumor-free. Finally, the exposed alveolar ridge is ground with the diamond bur. This is followed by repositioning. First start with the neck dissection on the left side. Skin incision. Exposure of the platysma, exposure of the sternocleidomastoid muscle and the digastric and omohyoid muscles. Exposure of the submandibular gland, exposure and preservation of the facial vein, successive evacuation of the anterior neck preparation with careful protection of the superior thyroid artery, exposure of the internal jugular vein. Resection of level V with careful protection of the plexus branches. A thoracic duct cannot be visualized. No evidence of lymph flow. Evacuation of level Va and the accessorius triangle with careful protection of the nerves. Exposure of the hypoglossal nerve and the common carotid artery with its division. Exposure of the vagus nerve. Now extirpation of the submandibular gland after removal of the digastric muscle and clearing of level Ib. Now continue to expose the hypoglossal nerve as well as the internal and external jugular. After further exposure, perform the pharyngotomy. After snaring the external and internal carotid arteries and securing the hypoglossal nerve, further resection of the tumor in the area of the lateral wall of the oropharynx and base of the tongue. The lingual nerve must be removed if there is tumor infiltration. Removal of the tumor in toto. This is sent for definitive histology. The edge samples are now taken again in the caudal region, all of which are also classified as tumor-free. Finally, sufficiently wide pharyngotomy. Now ab............. and measure the required graft. At the same time, a radialis graft elevation of approx. 13 x 6 cm and neck dissection on the right, initially for radialis graft elevation. Creation of a tourniquet. After marking the graft, excision of the graft using a skin monitor. Exposure of the superficial ramus, radial nerve, a true cephalic vein is not found. Strictly subfacial preparation. Exposure of the distal lobe pedicle. Deposition after puncture and ligation and ligation with very strict subperiosteal elevation of the graft with clipping of outgoing vessels. Two strong veins develop in the antecubital region, but they do not show any confluence and have no obvious direct connection. The double-barreled venous system is left in place and the radial artery is removed. After opening the tourniquet, vital graft and good conditions, later removal of the graft after ligation and puncture. Meticulous hemostasis and careful two-layer wound closure with full-thickness skin graft from the right groin. A 13 x 6 cm full-thickness skin graft is lifted from the groin for this purpose. Strictly cutaneous preparation. Careful mobilization and undermining of the surrounding tissue. There is a discrete protrusion in the area of the outer inguinal ring, questionable inguinal hernia, but no openings. Multi-layered subcutaneous suturing and skin suturing after insertion of a 10-gauge Redon drain. In the area of the forearm, final application of a vacuum supply and application of a cramp splint. Now to the neck dissection on the right side. Skin incision for this. Exposure of the platysma, cutting of the platysma, placement of a platysma flap. Exposure of the sternocleidomastoid muscle. A true external jugular vein is not found. Exposure of the auricularis magnus nerve. Exposure of the omohyoid muscle as well as the digastric muscle and the submandibular gland. Exposure of the internal jugular vein. Evacuation of the anterior neck level while sparing the superior thyroid artery, the facial vein and the cervical sinus as well as the hypoglossal nerve. Evacuation of the accessorius triangle with careful protection of the nerve and evacuation of level V with careful protection of the plexus branches. In the area of the veno-jugulofacial angle, a 3 cm large lymph node was found, which was macroscopically suspicious, otherwise there were no macroscopically suspicious masses in the area of the neck dissection. After extensive hemostasis with dry wound conditions, insertion of a 10-gauge Redon drain and two-layer wound closure. Now perform the tracheotomy. To do this, make a horizontal skin incision and cut through the skin layers. Identification of the linea alba and the cricoid cartilage. Exposure of the thyroid isthmus, transection of the isthmus. Exposure of the anterior surface of the trachea and insertion between the 2nd and 3rd tracheal ring and performance of the mucocutaneous anastomosis, which is successful and stable. Problem-free reintubation to an 8 mm tube. At the end of the operation, reintubation onto an 8-gauge cannula with a core, which is sutured in place. The graft is now removed. Sewing in the transplant. This is extremely difficult if the mouth opening is restricted. Successive transcervical and transoral placement and final suturing of the graft combined transorally and transcervically, which is relatively difficult with a narrow mouth opening, but is successful in the end. Good fit on all sides and reconstruction of the defect, which subtotally affects the soft palate, extends anteriorly to the buccal, dorsally exceeds the middle of the posterior pharyngeal wall. Reconstruction of the glossotonsillar groove and about 1/3 of the base of the tongue and the lateral wall of the oropharynx. Now vascularization. Expose the superior thyroid artery. After positioning the stalk, perform the arterial anastomosis after cleaning the vessels with 8.0 Ethilon. This is somewhat more difficult due to the vascular relationship, but is successful. Problem-free, good flap perfusion. After opening the vascular clamps, immediately very pronounced venous return with good flap perfusion. Both venous stumps now show high reflux with no clear differences. The decision is now made to anastomose the vein preferred by <CLINICIAN_NAME>. To do this, first remove the facial vein. There is complete thrombosis of the vein. Despite thrombectomy, shortening and heparin irrigation, recanalization is not successful. Another facial branch also tends to be thrombosed. Flow can only be generated if the branch is shortened back directly to the internal jugular vein, but there is no possibility of coupler anastomosis in the immediate vicinity, therefore ligation with primary in.................. Vessel diameter for the primary suture. Now also laborious vein search. Exposure of a superior thyroid vein. Here the anastomosis is successful with the size 2.5 coupler. Extremely difficult preparation conditions overall during vein preparation due to extremely thin vein walls and high vulnerability. Sufficient venous anastomosis with arterial flow, but pronounced reverse flow with multi-............. increased effect on the remaining vein. Therefore, no possibility of ligating this vein is seen here. Further laborious dissection and identification of another thyroid vein superior laborious dissection conditions. Finally, another Coupler anastomosis of size 2.5. After opening the arterial blood supply, sufficient venous anastomosis with excellent flap perfusion and vitality. Pedicle positioning and, in relatively dry wound conditions, insertion of a flap and very careful two-layer wound closure after monitor placement. Excellent flap aspects can also be seen here with enoral control. Termination of the procedure at this point. The patient received intraoperative antibiotics with Unacid, which should be continued postoperatively with Unacid 1.5 g for at least 3 days. Penetrating and hourly flap vitality check, for this purpose the superficial flap pedicle was marked with a thread, if the graft could not be completely overlooked due to the mouth opening. Please make sure to check the X-ray paps on the 9th to 10th postoperative day. Decannulation should be attempted in the medium term depending on the postoperative swallowing function. Due to the interoperative extension, certainly cT3 tumor, at least local adjuvant therapy is certainly indicated here.