After intubation by the anesthesia colleagues, pharyngoscopy and laryngoscopy again. This shows the deep ulcerated tumor with palpable infiltration even beyond the visible tumor borders. This once again confirmed the indication for surgery. Subsequently, PEG placement. PEG placement (<CLINICIAN_NAME>/<CLINICIAN_NAME>): Entering with the gastroesophagoscope and pre-scanning into the stomach under air insufflation. Spontaneous diaphanoscopy is given here, therefore indication for PEG insertion using the thread pull-through method. This was performed without any problems. Withdrawal of the endoscope. Then sterile draping and skin disinfection of all relevant surgical areas including the left forearm and right thigh. Tracheotomy (<CLINICIAN_NAME>/PJ): Due to the planned incision for the neck dissection, vertical incision on both sides for the tracheotomy. Exposure of the infrahyoid musculature. Entering the midline. Exposure of the thyroid isthmus. Dissection of the thyroid isthmus. Entering the trachea between the 2nd and 3rd tracheal clasp. Insertion of a visor tracheotomy in the typical manner. The mucocutaneous anastomosis is performed using Ethibond sutures. An 8-gauge cannula is inserted. Neck dissection on the right: Incision at the anterior edge of the sternocleidomastoid muscle in a curved line. Skin incision with the 15 mm scalpel. Skin is cut through. Subcutaneous tissue and platysma. Exposure of the anterior margin of the sternocleidomastoid muscle, lifting of the skin platysma flap. Exposure of the omohyoid muscle, internal jugular vein posterior to the digastric muscle and submandibular gland and accessory nerve. Now start with the release of the neck preparation in level IIb to level Vb. The branches of the cervical plexus are largely spared. The accessorius nerve is also spared. The vagus nerve is also spared, the hypoglossus is exposed and spared and the cervical artery and external carotid artery are also exposed and spared. Level IIa, IIb, III, IV, Va and Vb were thus evacuated. Punctual hemostasis and two-layer wound closure using 4-0 Vicryl and 5-0 Ethilon. Prior to this, placement of a 10-gauge Redon drain. Neck dissection on the left (dictation <CLINICIAN_NAME>): Incision on the anterior edge of the sternocleidomastoid muscle in a curved line. Skin incision with a 15 mm scalpel. Skin is cut through. Subcutaneous tissue and platysma. Exposure of the anterior border of the sternocleidomastoid muscle, lifting of the skin platysma flap. Exposure of the omohyoid muscle, the posterior venter of the digastric muscle of the submandibular gland and the accessorius nerve. Exposure of the internal jugular vein and the jugulofacial angle. This shows a metastasis that is connected to the internal jugular vein and facial vein and is carefully dissected off. Now start with the release of the remaining neck preparation in level Ib to level Vb. The branches of the cervical plexus are spared. The accessorius nerve is also spared. The vagus nerve is also visualized and spared. The hypoglossal nerve is visualized and spared as well as the cervical artery. The common, internal and external carotid arteries are now exposed and the superior thyroid artery, the facial artery and the ascending pharyngeal artery are dissected as possible connecting vessels. Levels Ib, IIa, IIb, III, IV, Va and Vb were therefore evacuated. Subsequently, combined transcervical and transoral tumor resection: Firstly, from the cervical side, dissection of the large neck vessels and dissection of the pharyngeal tube. This particularly concerns the external and internal carotid arteries. Exposure of the hypoglossal nerve and the vagus nerve, which are secured together with the cervical vascular sheath and the corresponding vessels using a vessel loop. Also exposure and preservation of the border cord. Stripping of the pharyngeal tube. The facial artery is already severed here. A large branch of the external carotid artery in the direction of the tonsil ligature is also ligated twice. Subsequent resection of the tumor: safety margin of at least 1.5 cm macroscopically. The palatal arch on the left falls away completely from the uvula, larger parts of the thyroid muscles, resection extends over the alveolar ridge, the glossoalveolar junction and into the base of the tongue. The lingual nerve cannot be preserved. Complete resection of the pharyngeal wall including parts of the base of the tongue. The submandibular gland is included in the preparation from the outside. The specimen is then marked with sutures and marginal samples are taken from the lateral alveolar ridge from the cranial side in the area of the palate and from the medial side from the palatal arch area to the beginning of the posterior pharyngeal wall. All marginal samples and also the entire tumor specimen in healthy tissue, i.e. R0 situation. This is followed by careful hemostasis. Measurement of the defect 10 x 8-9 cm. Now elevation of the radial flap: Dictation of <CLINICIAN_NAME> skin incision and dissection through the subcutaneous fatty tissue. Locate the cephalic vein and dissect it radially. Finding and dissection of the pedicle between the muscle bellies of the brachioradialis and flexor carpi radialis muscles in depth. Dissection of the venous star. Dissection of the cephalic vein, an accompanying vein and the interosseous vein as possible connecting vessels. Dissection of the radial artery up to the brachial artery. Now incision of the ulnar flap and subfascial dissection. Incision of the radial end of the flap with inclusion of the cephalic vein in the flap. This extends relatively far radially here. Further dissection of the pedicle with clipping of the perforator vessels. Further saturation of 100% after removal of the flap. Then suture the radial flap into the defect. This is done using 3-0 Vicryl single-button sutures, partly with pre-positioning. A tension-free and complete reconstruction of all areas is achieved. Then vascular sutures. Conditioning of the radial artery and the facial artery. Suture using 8-0 Ethilon single-button sutures. After opening the clamp, good arterial flow, good venous return. Subsequent conditioning of a V. thyroidea media and an outlet from the V. facialis. This is done using 3-0 and 2.5 mm couplers. In each case, good venous return after opening the clamps, positive smear phenomenon. Subsequent careful hemostasis. Irrigation. Layered wound closure on the right with insertion of a Redon drainage on the left with insertion of 2 flaps. Removal of split skin from the right thigh and closure of the left forearm with insertion of the split skin graft (dictation <CLINICIAN_NAME>/<CLINICIAN_NAME>) Removal of the split skin from the right thigh with the dermatome in the usual manner. Subsequent apposition of the arm. Insertion of a size 9 tracheostomy tube, followed by completion of the procedure without complications. Patient received Unacid intraoperatively. Please continue antibiotics for one week postoperatively. Please check the flap enorally and if necessary by Doppler according to the scheme for 5 days. Continue heparin perfusor at 1 mg per hour for about 5 days. Feeding via the inserted PEG tube for at least 10-12 days, then gruel and, if necessary, start to build up the diet. Overall cT2-3 oropharyngeal carcinoma on the left. Suspicious lymph nodes on both sides. Please wait for the final histology. Then presentation at the interdisciplinary tumor conference.