Tumor extension and tumor resection by <CLINICIAN_NAME>: Dictation <CLINICIAN_NAME>: First laryngoscopy and pharyngoscopy: The tumorous process is visible, which starts on the left next to the uvula and involves the entire tonsil lobe, pharyngeal side wall and runs to the base of the tongue and clearly infiltrates it. No crossing of the midline. Caudally, the process extends to the entrance of the piriform sinus. This confirms the indication for surgery. Initial positioning of the head, insertion of tonsil retractor and retractor alternately. Start resection from the transoral side: cut around the process with a safety margin of 1.5 to 2 cm on all sides. Take the soft palate including the uvula with you. Resection extends beyond the lower jaw, mucosa is pushed away from the lower jaw. Pharyngeal muscles and thyroid muscles are resected in a lateral cranial direction. Resection extends to just in front of the tube. About 60 % of the base of the tongue is resected. Marginal samples are taken from the palatal arch to the beginning of the alveolar ridge, from the alveolar ridge to the floor of the mouth, from the floor of the mouth to the tongue and from the base of the tongue, as well as marginal samples from the medial pharyngeal wall or posterior wall of the palatal arch in the cranial region. The caudal view is too poor, therefore the resection is continued after the neck dissection on the right, which is dictated separately. Resection of the digastric muscle with removal of the submandibular gland. Exposure of the internal and external carotid arteries, the internal jugular vein and the cranial nerves. The glossopharyngeal nerve is resected distally. The lingual nerve is also resected towards the floor of the mouth. The pharyngeal wall is detached from all vessels, as is the hypoglossal nerve, which is preserved. The tumor is resected cranially and pushed caudally under the lower jaw with resection of the masticatory muscles attached to the lower jaw. Caudal resection under vision, whereby the resection is carried out below the caudal tumor borders to a length of 2 to 3 cm. Margin samples are taken cranial basal, medial basal and caudal basal. A marginal sample is also taken from the caudal part of the medial pharyngeal wall with the piriform sinus extending to the aryepiglottic fold. All marginal samples are thread-marked for frozen section. In the frozen section, marginal specimen in the caudial medial pharyngeal area, piriform sinus area and arytenoid area with in situ infiltrates. Therefore, a generous resection of an approx. 1 cm wide strip from the area of the caudal pharyngeal wall of the piriform sinus and the areas of the medial arytenoid fold up to the border of the postcricoid region. Another marginal sample from this area. Despite the extensive laryngeal resection, the marginal specimen still shows almost continuous in situ infiltrates in the piriform sinus and in the arytenoid region extending to the postcricoid region. Thus, given the distance from the main tumor, there is a suspicion of extensive growth in the direction of the piriform sinus and postcricoidal region. Due to the expected dysphagia with further resection in the direction of the postcricoid region in view of the flat growth, no further resection is performed. Dictation <CLINICIAN_NAME>: In preparation for transcervical tumor resection, the neck is first dissected on the left side. To do this, make a curved skin incision on the anterior edge of the sternocleidomastoid muscle. Cut through the skin and subcutaneous tissue. Dissection of the platysma. Exposure of the sternocleidomastoid muscle, omohyoid muscle, submandibular gland and digastric muscle. Release of the anterior neck preparation while preserving the superior thyroid artery, the hypoglossal nerve and the facial vein; a small, superficial branch is removed. There are now several conspicuous nodules in levels II a and III. No evidence of perinodal growth or infiltration of the surrounding structures. Dissection of the internal jugular vein. Exposure and preservation of the accessorius nerve. Clearing of the accessorius triangle and level V with careful protection of the cervical plexus branches. Finally, no evidence of lymphatic leakage. Later, the external and internal carotid arteries are skeletonized to differentiate them from the enoral defect. Here, the lingual artery is exposed over a long distance. Subcapsular release of the submandibular gland is then performed. It can be seen that the cranial glandular cone is directly adjacent to the tumor. Therefore, this resection is performed together with the tumor resection. Removal of level I b. Several nodules up to 1.5 cm in size. The neck is now dissected on the right side. The procedure is basically the same. Expose the sternocleidomastoid muscle, omohyoid muscle, submandibular gland and digastric muscle. Clearing out the anterior neck preparation while preserving the facial vein, superior thyroid artery and hypoglossal nerve. Clearing of the accessorius triangle and completion of level V with careful preservation of the cervical plexus branches. In addition, the strong external jugular veins were spared on both sides. Careful irrigation of the wound. Insertion of a 10-gauge Redon drain and careful, two-layer wound closure. Plastic tracheotomy is then performed. This involves a horizontal skin incision below the cricoid cartilage. Cut through the skin and subcutaneous tissue. Exposure of the infrahyoid musculature. Dissection of the musculature. Exposure of the cricoid cartilage and the anterior surface of the trachea. Insertion between the 2nd and 3rd tracheal ring and creation of a broad-based pedicled Björk flap. Subsequent problem-free insertion of a size 8 suture-fixed low-cuff cannula. At the same time, the radialis graft was lifted from the left forearm. After measuring the defect, a graft configured for the floor of the mouth, tongue, tonsil lobe and pharyngeal side wall was lifted, measuring up to 15 x 11 cm in total. After marking and placement of the tourniquet, the graft is recut and an arc-shaped relief incision is made in the direction of the antecubital fossa. Radial exposure and entrainment of the cephalic vein. Expose and secure the superficial radial nerve ramus. An oblique branch towards the palm must be removed, otherwise the main branch must be preserved. Expose the distal vascular pedicle. Exposure of the brachioradialis muscle. Release of the distal vascular pedicle after ligation of the vessels. Ulnar preparation. Exposure of the flexor carpi ulnaris. Strictly subfascial graft release and dissection of the pedicle proximally with treatment of outgoing vessels. This shows sufficient confluence between the superficial and deep venous system, but clearly altered veins after puncture, so that the deep vessel is also included. After removal of the graft and careful hemostasis, the wound is carefully closed in two layers and the full-thickness skin graft harvested from the right groin is fitted. Finally, a good fit. Application of a vacuum sealing bandage and the Kramer splint in the functional position and repositioning of the arm. For full-thickness skin harvesting from the groin on the right. For this purpose, a graft measuring 20 x 8.5 cm is cut around an extensive graft, strictly cutaneous elevation. Extensive mobilization towards the abdomen and thigh fascia. Subsequently insertion of a 10 Redon drain in dry wound conditions and careful, multi-layered wound closure under moderate tension conditions. The graft is then inserted. This is considerably more difficult due to the extensive wound surface and exposed mandibular bone. However, the overall fit is good. Fitting of the graft with complete coverage of the resection area. Guide out the vascular pedicle cervically. Conditioning of the facial vein and the already prepared lingual artery. Perform the arterial anastomosis with 8.0 Ethilon. This is successful and sufficient. Immediate venous return exclusively via the deep venous system, therefore, after measuring a size 3.5 coupler, problem-free venous anastomosis with the facial vein. Subsequently, if the graft circulation is normal, a 10 Redon drain is placed after multiple wound inspections and the wound is carefully closed in two layers. Subsequently, if the graft is vital and the patient is stable, the procedure is terminated at this point without any indication of complications. Conclusion: At least cT3 cN2b G2 rCIS-resected oropharyngeal carcinoma on the left. Defect reconstruction using a radialis graft. Please continue antibiotics for 24 hours postoperatively. If the graft heals properly, food can be restored on the 9th to 10th postoperative day with good swallowing function. .