First, perform the PEG insertion. For this purpose, insertion with the gastroscope under laryngoscopic control. Easy pre-scanning into the stomach. Here, with good diaphanoscopy, problem-free puncture of the stomach and placement of the PEG tube using the usual thread pull-through method. Now turn to pharyngoscopy and initially transoral tumor resection. The left tonsil is clearly thickened, bulging, with central endophytic changes and otherwise exophytic parts. On palpation, it is noticeable that the tumor infiltrates the entire left soft palate submucosally from the tonsillar lobe, reaches hard to the hard palate border, extends to parauvular. Clearly infiltrates the posterior palatal arch. Here too, firm adherence to the posterior pharyngeal wall. Also submucosal growth through the soft palate towards the nasopharynx. Here, palpation and inspection reveal a free tubal bulge. The glossotonsillar groove is slightly raised but not infiltrated. The tumor is also adjacent to the alveolar ridge. Overall, absolutely immobile, almost completely submucosal tumor growth. The tumor is now resected using an electric needle and a dissection technique, subtotal resection of the soft palate to the right side, clearly parauvular. Resection up to the hard palate at the alveolar process, clear adherence in the area of the hard palate, therefore a small piece of bone is chiseled off here, but no signs of infiltration. Now resection of the soft palate. Overview of the growth towards the posterior pharyngeal wall and nasopharynx. Tumor growth to below the tubal bulge. Submucosal. Now resection to the buccal side and onto the alveolar ridge. Exposure of the ascending mandibular branch. Here also clear adherence but no infiltration, sharp incision of the periosteum here and pushing off with the raspatory. No evidence of osseous tumor infiltration here, visualization of the medial pterygoid, a clear displacement layer is now visible here, clearly no infiltration of the muscle, tumor can now be completely detached here. Resection cranially to below the tubal bulge, dorsally the resection extends to approximately the middle of the posterior pharyngeal wall, here at least 1 to 1.5 cm safety margin on all sides in the mucosal area. Preservation of the prevertebral fascia. Inclusion of a circumscribed tongue cuff with inclusion of the glossotonsillar groove, here a small tumor extension is visible towards the posterior floor of the mouth, this is also resected. Resection up to the submandibular gland. Due to the tight conditions here and in the area of the lateral pharyngeal wall with a palpable styloid process in clear proximity to the tumor, the decision was made to proceed further transcervically to secure the vessels. Taking marginal samples in the area of the entire soft palate and buccally. Also take a marginal sample in the direction of the nasopharynx. All marginal samples are tumor-free in the frozen section diagnostics. Therefore, repositioning for transcervical tumor resection. First perform the neck dissection on the left side. To do this, make a skin incision on the anterior edge of the sternocleidomastoid muscle. Cut through skin and subcutaneous tissue. Dissection of the platysma. Exposure and preservation of the external jugular vein and the auricularis magnus nerve. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle and the digastric muscle. Exposure of the submandibular gland. A macroscopically clearly enlarged lymph node measuring approx. 1 x 2 cm can be seen at the posterior edge of the gland. Exposure of the entire length of the digastric muscle. Identification of the accessorius nerve. Now remove the anterior neck preparation, carefully preserving the cervical artery, the superior thyroid artery, the facial vein and the hypoglossal nerve. Free preparation of the internal jugular vein. Here, conspicuous lymph nodes at the transition from level III to IV. Dissection of the vein, removal of the accessorius triangle with careful protection of the nerve. Evacuation of level V with careful protection of the cervical plexus branches. Minutious hemostasis. Caudal no evidence of lymphatic leakage. En bloc removal of the neck dissectate. Now turn to level Ib subcapsular excision of the gland, removal of the nodes in level Ib with careful protection. After visualization of the ramus marginalis mandibulae, removal of the nodes with gland. Now complete exposure of the hypoglossal nerve, resection of the digastric muscle, pharyngotomy is also performed by resecting the gland. Exposure of the carotid artery with the exit of the superior thyroid artery, the facial artery and the lingual artery. A branch of the facial artery and the lingual artery must be cut off. Laborious preservation of the facial artery. After exposing the carotid artery, expose the styloid process. Now a good overview of further tumor growth. In the case of tumor cones towards the floor of the mouth, the gland and the submandibular tissue as well as parts of the mylohyoid muscle are involved. Significant basal resection. This creates a wide safety margin in the cervical direction. After securing the vessels, the tumor can now be easily removed in the area of the pharyngeal side wall. After macroscopic examination of the tumor specimen, the macroscopic examination of the specimen in the area of the floor of the mouth revealed a scarce situation, but a tumor surrounded by a soft tissue margin. A pharyngotomy was carried out here for further resection. Also a close resection. Here non in sano resection in the area of the cranial oropharyngeal posterior wall or towards the nasopharynx. Due to the tumor progression shown on the entire specimen, generous resection in the area of the cranial oropharyngeal side wall and towards the nasopharynx. Otherwise, macroscopically clear in sano resection on all sides of the specimen with almost completely submucosal tumor growth as described above. The frozen section diagnosis now confirms the macroscopic assessment of a circumscribed basal scarce R0 situation in the area of the cranial oropharynx. Tumor margin forming here, but with free resectate. In addition, a very narrow basal resection margin is seen parauvularly, otherwise confirmation of the R0 resection. A generous resection of the entire soft palate is now performed transorally, resulting in total resection of the soft palate up to the right-sided tonsil lobe. This is diagnosed as completely tumor-free in the frozen section diagnosis. After exposing the defect, which now extends around the entire soft palate to the buccal, posterior floor of the mouth, tongue edge and oropharyngeal side wall, a transplant measuring approx. 11 x 6 cm in total is measured and adapted to the soft palate situation. In parallel, the radialis graft is lifted from the right and the neck dissection and the sonographically described intraparotid mass are performed. Intraoperative discussion of findings and sonography with <CLINICIAN_NAME>. First carry out the neck dissection. To do this, make an incision on the anterior edge of the sternocleidomastoid muscle, extending it preauricularly, and cut through the skin and subcutaneous tissue. Cut through the platysma. Exposure and preservation of the external jugular vein and the auricularis magnus nerve, exposure of the sternocleidomastoid muscle, exposure of the omohyoid muscle, exposure of the submandibular gland and the digastric muscle. Identification of the accessorius nerve. Clearing of the anterior neck preparation with careful protection of the superior thyroid artery, the cervical sinus, the hypoglossal nerve and the facial vein. Clearing of the accessorius triangle with careful protection of the nerve and clearing of level V with careful protection of the cervical plexus branches, overall significantly more difficult preparation conditions due to the simultaneous surgical procedure. Now placement of a parotid lobule anteriorly. Preservation of the auricular nerve, a well-defined lesion can now be palpated at the caudal pole of the gland. Superficial and caudal location, therefore decision to perform extracapsular dissection. Resection of the mass with surrounding glandular mantle in toto, macroscopically most likely corresponding to a cystadenolymphoma independent of the tumor. The facial nerve can be stimulated in depth without any problems. However, there is no exposure of nerve branches at any point. Careful wound inspection. Meticulous hemostasis and, after wound inspection and irrigation, insertion of a 10-gauge Redon drain and careful two-layer wound closure. Now turn to lifting the radialis graft. After marking the graft, apply the tourniquet. Cut around the double-bellied graft. Exposure and entrainment of the cephalic vein. Exposure of the superficial radial ramus. Strict subfacial dissection. Exposure of the peripheral vascular pedicle after peripheral removal of the cephalic vein. Separation of the radial vascular pedicle after ligation. Careful subfacial dissection. Meticulous protection of the vascular pedicle. Lifting of the graft using a small muscle cup in the area of the vascular pedicle with adherence up to the crook of the elbow. Exposure of the vascular situation. Exposure of the emergence of the anterior interosseous artery, exposure and securing of the ulnar artery, which is very strong. Exposure of a strong venous vascular bridge between the deep radial venous system and the superficial subcutaneous venous system. Reliable and safe elevation of the cephalic vein is therefore possible. Dissection of the vein up to the crook of the elbow. Isolate a double-headed venous vascular pedicle here. After careful clipping of all outgoing vessels, isolate the radial artery and the superficial venous outflow. Reopening of the tourniquet. Excellent hand and graft perfusion. Minutious hemostasis and, if flap vitality is excellent, removal of the graft after ligation. Preservation of the anterior interosseous artery. Now careful wound inspection, final hemostasis and careful two-layer wound closure and incorporation of the full-thickness skin graft from the groin. Finally, the wound is dressed with a vacuum dressing and a Cramer splint. Due to the good visibility of the graft, a monitor was not used in favor of the lifting defect in the arm area. Full-thickness skin graft from the groin. After marking a full-thickness skin graft measuring approx. 13 x 6 cm in a spindle shape. Cut through the skin and lift the graft strictly cutaneously. Final thinning with scissors. Careful subcutaneous mobilization on all sides and, after careful hemostasis, careful two-layer wound closure after insertion of a 10-gauge Redon drain with moderate tension ratios. In the meantime, as with the tumor resection, a tracheostomy was performed due to cuff insufficiency. For this purpose, the tracheostomy was performed approx. 1 cm below the cricoid cartilage and the skin and subcutaneous tissue were cut. Cut through the infrahyoid muscles. Exposure of the cricoid cartilage, 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. Subsequently, initially problem-free transfer to an LI tube. Then reintubation onto an 8-gauge cannula with inner core and suturing of the cannula. The radialis graft is now inserted. To do this, first place sutures in the area of the nasopharynx and in the area of the dorsal soft palate or the soft hard palate border and suture in the area of the right tonsil lobe. Pulling through the graft, suturing to the sutures provided. The graft can now be easily folded over to create a neo-soft palate. Good fit of the graft, reconstruction also in the area of the cheek and in the area of the alveolar ridge, suturing in the area of the tongue. With intact conditions on all sides, completion of the transcervical suture. Suture in the area of the tongue edge and the pharyngeal side wall. Finally, intact and tight conditions on all sides. Further transoral check of the suture. Here too, very good fit and, with intact conditions, now turning to microvascular anastomosis. Preparation of the pedicle vessels. Then preparation of the cervical vessels. This reveals a relatively weak superior thyroid artery, hence preparation of the facial artery, which is stronger but has a somewhat unfavorable course. Therefore, the artery is traced, the artery is removed after free dissection and beaten caudally. Despite a significantly stronger facial artery with a moderate caliber jump, the arterial anastomosis is now performed with 8.0 ethilon. This is extremely difficult due to the positioning of the vessels and the different vessel diameters. Successive adjustment of the vessel edges. After reopening the Acland clamp, immediate regular perfusion with immediate regular venous flow, tight arterial conditions, regular graft perfusion. Then prepare for venous anastomosis. To do this, remove the strong facial vein after ligation. Thrombosis is evident here, therefore clean the facial vein and shorten it back with now free conditions and regular venous bleeding. Performing the anastomosis with the Coupler 4.0, which is somewhat more difficult due to the vulnerable vessel wall of the facial vein. After performing the coupler anastomosis, there is a leak in the area of the venous anastomosis, which cannot be fixed with sutures. The venous anastomosis is therefore cut out with the coupler. Rerouting of the anastomosis also with Coupler 4.0. Now intact conditions and regular venous outflow. After reopening the artery, regular circulation and excellent perfusion of the graft. Final positioning of the vascular pedicle even with closure of the wound surfaces, no torsion. Therefore, after multiple wound inspections with good flap perfusion, insertion of a long rubber flap with caudal drainage and careful two-layer wound closure with residual cervical opening for hematoma prophylaxis caudally. Intraoperatively, the patient repeatedly experienced diffuse and increased bleeding tendencies, which could, however, be well controlled conservatively and surgically. The patient was subsequently transferred to the intensive care unit on mechanical ventilation. Conclusion: Extensive and highly aggressive cT3 cN2c G2 oropharyngeal carcinoma on the left due to submucosal and infiltrative growth. Due to the intraoperative extension and the extensive submucosal growth, adjuvant radiochemotherapy is certainly urgently required here, also due to the interoperative R0 situation. Postoperatively, please monitor the flap meticulously by inspecting the pharynx. Postoperatively, a round gruel swallow should be performed on the 8th postoperative day. Depending on the swallowing function, decannulation can be performed promptly if necessary. Secondary findings: smooth and macroscopically rather benign mass of the right parotid gland.