After intubation by the anesthesia colleagues and preparation for the procedure, pharyngoscopy is performed to determine the extent of the mass. An exophytic mass was found in the area of the left tonsillar lobe. Infiltration of the anterior and posterior palatal arch. Growth over the glossotonsillar groove into the edge and base of the tongue with palpatory submucosal growth towards the posterior floor of the mouth, overall cT3, therefore primarily transoral resection. Incision of the tumor with a safety margin of a good 1 cm, including the anterior and posterior palatal arch. Resection in a parauvular direction. In the case of deep infiltration, expose the pterygoid muscles. Inclusion of the posterior palatal arch and here also the muscles basally here in sano. Resection up to the alveolar ridge, here small tumor extension, therefore circumscribed bone exposure in the area of the posterior mandible. Detachment of the periosteum here. Now resection towards the posterior floor of the mouth, here the tongue shows submucosal infiltration at the edge and base of the tongue. Resect the base of the tongue generously while maintaining a safety distance of at least 1.5 cm. Release of the tongue section. It is now apparent that the tumor has grown submucosally over the posterior floor of the mouth towards the cervical region, with insufficient control, so that the combined procedure via a transcervical approach is now decided upon. Imaging of the entire enoral tumor in the area of the mucosal margins as well as basally with margin samples, these are diagnosed as completely tumor-free. Then turn to the transcervical approach. Skin incision at the anterior edge of the sternocleidomastoid muscle. A rough, hard mass can be palpated in depth at the cranial edge of the sternocleidomastoid muscle. The same applies to levels II and Ia. Cut through skin and subcutaneous tissue. Expose and dissect the platysma. Dissection of the platysma. Exposure of the sternocleidomastoid muscle, exposure of the omohyoid muscle, exposure of the submandibular gland and the digastric muscle. Release of the anterior neck preparation with careful protection of the superior thyroid artery and the superior thyroid vein, which is very strong here. Cranial dissection of the sternocleidomastoid muscle shows clear infiltration. Therefore, the muscle is removed at the level of the omohyoid muscle, cranial dissection with the neck preparation up to level Vb with numerous nodes, targeted ligation of the thoracic duct. After visualization, no evidence of lymphatic leakage. Cranial dissection, caudal preservation of the cervical plexus. Cranially, the metastasis is markedly coarse and hard to palpate, firmly infiltrating the surrounding tissue. Involvement of the sternocleidomastoid muscle up to its cranial origin. Involvement of paravertebral musculature. Resection of the accessorius nerve with parts of the cervical plexus. Dissection of the internal jugular vein, which is clearly infiltrated cranially. Retention of the outlet of the superior thyroid vein. In the case of extensive perinodally growing metastasis or soft tissue metastasis, the .............. The internal jugular vein as well as the vagus nerve, the carotid bulb and the branches of the external and internal carotid arteries are also surrounded by tumors. Clear infiltration of the hypoglossal nerve. Careful dissection of the common carotid artery and the carotid bulb with dissection of the perivascular tissue allows the tumor to be removed in toto from the carotid bulb and the internal carotid artery. No wall infiltration, but long-lasting involvement of the internal carotid artery. With removal of the entire perivascular tissue and resection of the structures already described as well as resection of the caudal parotid pole, a mass can now be resected in toto. Resection, the mass moves under the digastric muscle in the direction of the tonsillar lobe. Now there is no complete tumor growth, so that a direct metastatic pathway is present. Tumor infiltration towards the muscles of the floor of the mouth is now also evident. Palpation from the outside through the primary tumor initially leads to resection of the digastric muscle, triggering of the submandibular gland, here in level Ib multiple and macroscopically highly visible masses, which are excised in toto. Exposure of the long marginal mandibular ramus, which is not infiltrated and can be preserved. Resection of the submandibular gland. Here, creation of the connection inwards to the enoral transresection margin. Final resection of the primary tumor, including the floor of the mouth, muscles and lateral pharyngeal muscles. Here in toto on all sides. A complete image of the tumor and the basal musculature is now made at the caudal site of the base of the tongue and the caudal pharyngeal wall; these are also diagnosed as completely tumor-free in the frozen section diagnosis. Overall, an R0 situation can be assumed here as far as it can be imaged using marginal samples. The anterior excision of level Ib and the excision of level Ia are now performed. Level Ia shows a highly suspicious lymph node and a further soft tissue metastasis. Release under resection of the anterior venter of the digastric muscle, resection of the metastasis with surrounding and floor muscles but without infiltration. After enoral complete evacuation of level Ia. Careful inspection of the wound area. Overall dry conditions. The lingual artery was removed. Likewise, outlets of the facial artery, otherwise existing arterial supply and existing caudal internal jugular vein with ultimately remaining tributaries of the superior thyroid and middle thyroid vein. Subsequently, parallel neck dissection of the right side and elevation of the antero-lateral thigh graft from the right after measurement of the defect and confirmation of the R0 situation. First to the neck dissection on the right. This also involves a curved incision at the anterior edge of the sternocleidomatoid muscle, cutting through the skin and subcutaneous tissue. Exposure and dissection of the platysma. Exposure of the sternocleidomastoid and omohyoid muscles. Exposure of the submandibular gland and digastric muscle. Removal of the anterior neck preparation with careful protection of the cervical vein, the facial vein, the superior thyroid artery and the hypoglossal nerve. Free preparation of the internal jugular vein. Exposure of the accessorius nerve, clearing of the accessorius triangle and clearing of level V with careful protection of the cervical plexus branches. In level II, conspicuous nodes also paraglandular in the area of the submandibular gland, several nodes clearly suspicious in number and size. Release of the submandibular gland. Clearing of level Ib, exposure of the marginal mandibular ridge and careful protection of the nerve. Complete evacuation of level Ib, macroscopically highly conspicuous nodes in number and size. Complete the dissection to level Ia. Finally, extensive wound irrigation and, if the wound is dry, insertion of a 10-gauge Redon drain and careful two-layer wound closure. Then turn to the plastic tracheotomy: To do this, make a horizontal skin incision approx. 1 cm below the cricoid cartilage. Cut through skin and subcutaneous tissue. Ligation of the left-sided anterior jugular vein. Entering the linea alba, exposing the cricoid cartilage, exposing the anterior wall of the trachea. Dissection of the slender thyroid isthmus. Further exposure of the anterior wall of the trachea. Insertion between the 2nd and 3rd tracheal ring. Creation of a broad-based pedicled Björk flap. Subsequent successive insertion of the tracheostoma. Subsequent problem-free intubation onto a size 9 low cuff cannula, which is suture-fixed. Now to lift the anterolateral thigh graft. After marking the landmarks, double sonographic identification of the main perforator and 2 secondary perforators. Marking of the graft configured for the tonsil lobe, pharyngeal side wall and tongue, measuring approx. 11 x 9 cm in total. Medial incision. Separation of skin and subcutaneous tissue, exposure of the facia lata, reliable identification of the rectus femoris muscle, strictly subfascial preparation. Visualization of the pedicle vessel. Inspection reveals the sonographically visualized perforators which, however, are extremely slender. Execution of the relief incision and further exposure of the pedicle vessel. Complete resection of the graft, including the fascia lata. In the case of a circumscribed myocutaneous course of the perforators, a narrow muscle strip is removed after identification of the distal vascular pedicle. After identification of the perforator level, elevation of the graft, isolation on the vascular pedicle. Dissection of the vascular pedicle, visualization of a venous confluence. Exposure of the transverse ramus. Subsequently, if the graft is in proper vitality, the graft is removed after ligation of the feeding and draining vessels. Careful wound inspection and, if the wound is dry, insertion of a 10-gauge Redon drainage and then careful multi-layer wound closure with smoothing of excess skin. The combined transoral and transcervical insertion of the graft is now performed. Overall extremely good fit and intact conditions on all sides. Reconstruction of the soft palate, the tonsil lobe, the pharyngeal side wall and the base and edge of the tongue, as well as the posterior floor of the mouth. Conditioning of the superior thyroid artery and the superior thyroid vein. Perform the arterial anastomosis using the single suture technique with 8-0 Ethilon. This succeeds immediately without any problems. Regular venous return and vital graft. Performing the venous anastomosis with the coupler system using a size 3.5 coupler. Finally, regular circulation, good pedicle pulsation as well as a positive smear test and a regularly vital graft enorally, so that after a final wound inspection a 10 redon drain is inserted and the wound is carefully closed in two layers. During the recovery phase, a moderate degree of ballooning of the neck becomes apparent if the right Redon drainage is not pumped, so re-exploration is performed at the end. Removal of the hematoma, hemostasis in the area of smaller muscle vessels, careful wound irrigation with H202 and Ringer's solution and, if the wound was absolutely dry, re-insertion of a 10-gauge Redon drain and careful two-layer wound closure and completion of the procedure with a vital graft. The patient received intraoperative intravenous antibiotics with clindamycin 600 mg, which should be continued for 24 hours postoperatively. If possible, leave the suture-fixed cannula in place for 5 days postoperatively. Carry out an X-ray pre-swallow on the 10th postoperative day, then evaluate the swallowing function. Due to the radical tumor resection and the extended radical neck dissection on the left with resection of the vagus nerve and hypoglossal nerve, a protracted recovery of swallowing function can be expected here. Overall intraoperative R0 resected, at least cT3 cN2c oropharyngeal carcinoma on the left with clear soft tissue metastasis and multiple conspicuous nodes, especially level Ia and level Ib on both sides. Rapid initiation of adjuvant RCT appears to be urgently required here.