First, pharyngoscopy and laryngoscopy again. Insertion of the McIvor blade. Inspection of the tumor. This extends from next to the uvula over the tonsil and lateral pharynx area to the base of the tongue. Placement of the PEG: insertion of the esophagoscope. After creating the diaphanoscopy, insertion of a 15 mm abdominal wall tube in a typical manner without complications. Fixation to the abdominal wall typically without any problems. First start with tumor removal transorally: tumor is incised on all sides with a safety margin of at least 1 to 1.5 cm and is extirpated in toto. The soft palate up to the uvula, the tonsil and adjacent pharyngeal side wall as well as the caudal mucosa up to the hypopharyngeal junction or the junction at the base of the tongue are removed. Tumor is thread-marked. Basally another marginal sample. In the frozen section in all directions in healthy tissue, except caudally, where there is still growth under the epithelium in the soft tissue. Therefore, resection from the outside is indicated. The patient is now positioned and all relevant surgical areas are disinfected. First neck dissection on the left: Skin incision in typical manner. Exposure of the sternocleidomastoid muscle, omohyoid muscle and digastric muscle. Exposure of the submandibular gland. Exposure of the internal jugular vein, facial vein, internal/external carotid artery. Exposure and preservation of hypoglossal nerve and vagus nerve. Clearing out levels II to V while preserving the branches of the cervical plexus. Subsequent transection and removal of the digastric muscle. Removal of the submandibular gland. Skeletonization of the hypoglossal nerve again. Exposure of the facial artery up to the exit from the area of the lingofacial trunk. The lingual artery is severed and struck caudally with the facial artery. Now overview of the tumor with defect in the pharyngeal space. Extensive resection of the soft tissue in the caudal margin of the former tumor, whereby the hyoid bone, superior cornu and parts of the external musculature around the hyoid bone are also resected up to the beginning of the vallecula. Subsequently, extensive marginal sampling of the mucosa caudally from the pharyngeal wall over the piriform sinus to the arytenoid region, with soft tissue underneath and with preservation of the superior laryngeal nerve. In addition, extensive soft tissue resection in the area of the vallecula. The latter two go to the frozen section. No more tumor infiltrates, thus R0 situation. Definitive indication for defect coverage using a radial flap. Neck dissection on the right by <CLINICIAN_NAME>: Marking of the skin incision in consultation with <CLINICIAN_NAME>. Incision of the cutaneous and subcutaneous tissue. Incision of the platysma with protection of the external jugular vein and the auricular nerve. Attachment of the upper edge of the platysma and subplatysmal dissection approx. 1.5 cm cranially until the submandibular gland is exposed. Open the glandular capsule and elevate the capsule to protect the marginal nerve. Attachment of the lower platysma margin and subplatysmal dissection approx. 1 cm caudally. Exposure of the anterior margin of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. Dissection of the omohyoid muscle up to the hyoid bone. Exposure of the posterior venter of the digastric muscle and dissection along the muscle ventrally to the hyoid bone. Dissection along the sternocleidomastoid muscle in depth to the cervical plexus. Division of the neck preparation from caudal to cranial along the internal jugular vein. Identification of the hypoglossal nerve and the accessorius nerve. The neck preparation (lateral) is detached from the deep cervical fascia from cranial to caudal. Care is taken to spare the branches of the cervical plexus and the accessory nerve. The common carotid artery and the vagus nerve are exposed. All structures can be preserved. Overall, regions Ib to IV are included in the neck preparation. After removal of the lateral preparation, the medial preparation is now prepared and removed. The branches of the external carotid artery can be left intact. Irrigation of the wound with hydrogen and Ringer's solution. Overall, the wound is completely dry. Placement of a 10-gauge Redon drain and two-layer wound closure with a platysma and skin suture. Tracheostoma creation by <CLINICIAN_NAME>: Transition to tracheostomy. A skin incision is made 1.5 QF below the thyroid cartilage. Careful dissection up to the trachea with careful hemostasis. Transverse incision of the trachea between two cartilages while protecting the tracheal tube. The operation is now briefly interrupted to suture in the flap. This is performed by <CLINICIAN_NAME>. Subsequent mobilization of the subcutaneous tissue and mucocutaneous epithelialization by <CLINICIAN_NAME>. The radialis flap is now elevated from the left forearm. Mark the size of the flap on the forearm approx. 9 x 6 cm. First cut around the flap from the ulnar side. Extend the incision towards the crook of the elbow. Exposure and preservation of the superficial venous system. Subsequent subfascial elevation of the flap from the radial side. Exposure and preservation of the lateral antebrachial cutaneous nerve. Exposure of the radial artery caudally. This is first clamped off. Flap is further elevated subfascially from ulnar and radial. The vascular pedicle is exposed up to the elbow. Connection between superficial and deep venous system is visualized. Venous outlets from the superficial venous system can be visualized. The radial artery is then severed and treated using 4.0 Prolene single button sutures using the puncture technique. Hand always well perfused up to this point, saturation at 100 %. Lifting of the flap subfascially. Smaller vessels are ligated or clipped or treated bipolarly. Lift up to the elbow area, here the radial artery and the vein of the deep venous system can be visualized. These are relatively small. However, there are 3 large veins of the superficial venous system, which are connected to the deep venous system. The flap is then removed. Veins are ligated. The brachial artery is supplied by puncture ligation. The flap is then flushed with heparin solution and preserved. Transition to defect coverage with <CLINICIAN_NAME>. Marking of the graft. Cut around the graft and make a curved skin incision up to the elbow. Exposure of the brachioradialis muscle. Exposure of the cephalic vein and the outlets in the superficial system. Visualization of the venous confluence. Exposure of the superficial ramus of the radial nerve, which is spared. Exposure of the radial artery. Separation and transection of the radial artery. Lifting of the radial artery graft from the tendon bed and dissection of the pedicle up to the elbow. Removal of the pedicle while preserving the interosseous artery and the ulnar artery. One vein is lifted from the deep system and two veins from the superficial system. Suturing of the arm in the usual manner with coverage by split skin from the right thigh. Application of a dorsal forearm splint. Suturing of the graft largely from the transcervical side. Start suturing in the piriform sinus, then in the vallecula, then on the lateral pharyngeal wall and the last part transorally in the area of the soft palate and the edge of the tongue. The stalk is diverted to the left and connected to the lingual artery and the facial vein, the external jugular vein and another branch from the internal jugular vein. This means that a triple venous anastomosis and a single arterial anastomosis were performed. Insertion of a Redon drainage. Two-layer wound closure. Patient goes to the intensive care unit for postoperative monitoring. Antibiotics, which were started intraoperatively with Unacid, should be continued for 1 week. Control of the radial flap in a typical manner for 5 days according to the scheme. Continue herparin perfusor 500 units per hour for 5 days. Feeding via the inserted PEG tube. After 10 days, swallow porridge, then build up diet if necessary. Wait for the final histology and then presentation at the interdisciplinary tumor conference to plan further adjuvant therapy.