Introductory consultation with the anesthesiologist. After reclination of the head, pharyngoscopy and laryngoscopy again: The described tumor is seen, which starts next to the uvula on the left, extends over the palatal arch and the tonsillar lobe to the base of the tongue. The tumor grows in the area of the cranial oropharyngeal side wall ulcerating in depth. Therefore, flap coverage is also indicated according to the CT findings. PEG placement is performed first: insertion of the flexible esophagoscope. Push through into the stomach. After creating the diaphanoscopy, insertion of a 15 mm abdominal wall tube in a typical manner without complications. Fixation of the abdominal wall in the typical manner. Then repositioning of the patient. Skin disinfection, sterile draping of all relevant surgical areas. Start with the neck dissection on the left: Skin incision curved in a typical manner. Exposure of the sternocleidomastoid muscle, exposure of the omohyoid muscle, digastric muscle. Exposure of the submandibular gland. Exposure and preservation of the common carotid artery, internal/external carotid artery, internal jugular vein, vagus nerve, accessorius nerve, hypoglossal nerve. Displacement, neurolysis and re-embedding of the vagus nerve, accessorius nerve and hypoglossal nerve. Also visualization of the branches of the cervical plexus. Development of the posterior neck preparation and later also the anterior neck preparation. This results in the removal of levels II-V. All branches of the cervical plexus were exposed and preserved. Neck dissection on the right: skin incision as on the opposite side. Exposure of all structures as on the opposite side. Displacement, neurolysis and re-embedding of the vagus nerve, accessorius nerve and hypoglossal nerve. This results in a level II-IV neck dissection and smaller parts of V. All structures are exposed and preserved as on the opposite side. Tracheostoma creation: Small Kocher's cross-section. Dissection through the subcutaneous tissue to the infrahyoid musculature. Spreading of these. Exposure of the thyroid isthmus. Undercutting, clamping, severing and ligation using puncture ligatures. Exposure of the trachea. Preparation of a small wide-pedicled Björk flap. Epithelization of the same in a typical manner. Insertion of a laryngectomy tube. Tumor resection from the transoral and trancervical side, initially from the left side of the neck dissection. Dissection of the external carotid artery, internal carotid artery, vagus nerve, hypoglossal nerve, accessorius nerve and internal jugular vein as well as the superior ganglion from the pharyngeal wall. Nerve vessels are dissected from the pharyngeal tube up to the base of the skull. No tumor infiltrates visible here. The submandibular gland is also extirpated. The lingual nerve is exposed and preserved. Displacement, neurolysis and re-embedding of the same. The digastric muscle is also resected. All important vessels and nerve structures are then looped using Vesselloops and pulled to the side. Transorally, the tumor is incised on all sides with a safety margin of at least 1.5 cm. This results in the removal of the entire pharyngeal wall including the attached soft tissue up to the level of the piriform sinus entrance. Resection extends inwards to the base of the tongue. Approximately 20% of this is resected. The posterior pharyngeal wall is partially resected. The tumor specimen is thread-marked and sent for frozen section diagnostics. Similarly, marginal samples are taken from the palatal arch, from the pharyngeal wall medially, from the transition from the posterior palatal arch to the tonsil, from the lateral in the form of the uvula and a soft tissue marginal sample from the cranial-basal side. In the frozen section preparation, taking into account the marginal samples in healthy tissue. Unclear situation at the transition from palatal arch to medial pharyngeal wall. Therefore, another cranial-medial margin sample was taken from the pharyngeal wall at the junction of the tonsillar lobe and palatal arch. No tumor infiltrates in the frozen section here either. Thus a definitive R0 situation. The result is a defect on the palatal arch extending beyond the uvula, posterior pharyngeal wall, lateral pharyngeal wall up to the entrance of the piriform sinus and the base of the tongue and vallecula up to the epiglottis. A radial lobe is measured in terms of length, width and three-dimensional shape. The radial lobe is then elevated from the left forearm: Mark the radialis flap, which reaches 13 cm in length and 8 cm in maximum width. First lift the flap from the ulnar side. Then extend the incision into the crook of the elbow. Exposure of the vascular pedicle, exposure of the superficial vascular system. Then lift the flap from the radial side. Deposition of the flap distally and ligation of the radial artery cranially and caudally using 4.0 Prolene sutures. The flap is then lifted subfascially along its pedicle, including the superficial venous system. Outgoing vessels are bipolized or treated with clips, larger ones are ligated. Cranial view of the connection between the superficial and deep venous system. There is only a rudimentary venous outflow via the radial vein, which is divided into smaller vessels. These are clipped. The interosseous artery is very small and is clipped. The flap is removed at the brachial artery and two larger branches from the cephalic vein. The veins are ligated. The artery is supplied with a 6.0 Vascufil suture. Saturation during the elevation is always 100%, clinically no abnormalities. The flap is flushed with heparin. Subsequent insertion of the flap: insertion into the defect. Successive incorporation of the flap into the defect using 3.0 Vicryl single-button sutures, which is successful without tension. Flap suturing partially with sutures in place. Subsequent arterial anastomosis. The superior thyroid artery is selected. After conditioning the vessels, suture with 8.0 Ethilon single-button sutures. After opening the clamp, good arterial flow, good venous return. Conditioning of the two outlets of the cephalic vein. One outlet is anastomosed with an outlet from the facial vein. Anastomosis is performed after conditioning the vessels with a 2.5 mm coupler. The other outlet is then anastomosed with an outlet from the V. thyroidea media after conditioning the vessel ends using a 2.5 mm coupler. Again, after opening the vessels, good venous return, positive smear phenomenon. This is followed by extensive irrigation of the neck wounds on both sides and careful hemostasis. Wound closure in layers with insertion of a Redon drain on both sides. Pressure dressing on both sides. Covering the forearm defect on the left: For this purpose, a 0.7-0.8 mm thick split-thickness skin graft is obtained from the thigh according to size. This is successively incorporated into the forearm skin defect. Application of a hydrogel-Mepilex dressing. Application of a loose compress dressing, wrapping with absorbent cotton. The arm is fixed in a Kramer splint in a functional position and wrapped with an elastic bandage. The arm was applied before the anastomosis suture. Arm always well perfused, saturation 100%. Finally, removal of the laryngectomy tube. Insertion of an 8 mm tracheostomy tube, which is fixed with sutures. Completion of the procedure without complications. The patient is intubated and ventilated and transferred to the intensive care unit for monitoring. Final consultation with the anesthesia department. Please continue heparin perfusor 500 I.U./hour as started intraoperatively, also postoperatively for 5 days. Check the blood circulation of the flap clinically and via suture marking on the left side of the neck in a typical manner according to the plan. Please continue antibiotics as started intraoperatively with Unacid 3 g for 2-3 days. Feeding for approx. 10 days via the inserted PEG tube, then gruel and, if necessary, diet build-up. Determine adjuvant therapy according to the final histological findings in the interdisciplinary tumor conference.