Detailed consultation with the anesthesia department. Positioning of the patient. Performing a pharyngoscopy. An extensive tumorous process of the right oropharynx is seen, growing predominantly submucosally, infiltrating approximately half of the soft palate, palpating hard to the transition of the soft palate. Tonsil lobe is tumorously depleted and massively widened. Transition to the posterior pharyngeal wall. The tumor is completely fixed in its surroundings, no mobility. The tumor extends dorsally close to the alveolar ridge, but does not appear to infiltrate it. On palpation, the base of the tongue is infiltrated to about one Ľ. The CT already shows continuous growth towards the cervix with direct transition to an extensive cervical metastasis, clinically with a coarse, moderately displaceable mass measuring approx. 8 x 6 cm cN3 neck status. First, transoral resection was performed to mobilize the tumour cranially. To do this, cut around the tumor in the soft palate while maintaining a safe distance of a good 1 cm. Subtotal entrainment of the soft palate up to the hard palate border. Adherence here but no infiltration. Therefore, detachment of the process from the hard palate with the Rasper with circumscribed exposure of the bone at this point. Cut around the soft palate buccally. Small tumor cone behind the alveolar ridge towards the buccal side, otherwise no infiltration here, but with pronounced fixation, highly suspected infiltration of the pterygoid musculature. Therefore, the tumor is cut around in the area of the soft palate and buccally. Release from the nasopharynx with resection close to the right tube. However, the tube is still spared. Exposure and mobilization of the pterygoid muscles. Significant infiltration here. Removal of the pterygoid muscles, exposure of the ascending mandibular branch. If there is clear adherence to the posterior mandibular ridge, incision here, paradental removal of the periosteum, thus clearly separating the tumor from the bone. Clearly no infiltration or periosteal perforation. The solution is later completed transcervically at the site of the posterior mandible. Transcervical resection is now performed in the case of an extensively fixed tumor that is growing continuously into the neck. Prior to this, covering samples are taken from the soft palate, the nasopharynx and the buccal margin. These are diagnosed as tumor-free in the frozen section diagnostics. Now repositioning, initially for tracheostomy. For this purpose, a horizontal skin incision is made below the cricoid cartilage and the skin and subcutaneous tissue are cut through. Exposure of the infrahyoid musculature, fissures along the linea alba. Exposure of the cricoid cartilage, exposure of the anterior wall of the trachea. Mobilization of the thyroid isthmus, transection of the slender isthmus after strong bipolar coagulation. With a relatively deep-seated larynx between the 1st and 2nd tracheal ring, insertion of a broad-based pedicled Björ flap and incision of the tracheostoma with mucocutaneous anastomosis. Subsequent problem-free intubation onto a 9 mm low cuff cannula, which is suture-fixed. Now repositioning first for radical neck dissection with subsequent completion of the tumor resection. To do this, make a skin incision over the extensive metastasis, curved at the anterior edge of the sternocleidomastoid muscle. Cut through skin and subcutaneous tissue. Exposure of the platysma. This is completely preserved and can be separated from the metastasis with a sliding layer. Therefore creation of a platysma flap anteriorly and above all dorsally. Complete exposure. The metastasis infiltrates and destroys the sternocleidomatoid muscle over a large area and appears to be located in the paravertebral musculature. Therefore, first caudal visualization of the sternocleidomastoid muscle. Showing the omohyoid muscle. Visualize the submandibular gland, visualize the digastric muscle. First visualization of the anterior venter. In the middle there is a clear adherence or infiltration of the digastric muscle, release of the anterior neck preparation with exposure and later removal of the cervical artery. Exposure and preservation of the superior thyroid artery. Caudal exposure of the internal jugular vein. This is exposed caudally. Dissection of the vein, this is seen just cranial to the outlet of the facial vein, initially displaced, later clearly infiltrated. The facial vein is also infiltrated cranially. Therefore, both vessels are removed after double ligation. Caudal release, transection of the sternocleidomastoid muscle. Dissection and release of level 5, showing clearly macroscopically enlarged, partly lividly discolored lymph nodes, therefore also removal of level 5b, mobilization of the omohyoid muscle, removal of the level up to the end of the clavicle. Careful protection of lymphatic structures, no exposure of the subclavian vein. Finally, after meticulous hemostasis, no evidence of lymphatic leakage. Cranial dissection of the extensive perinodal metastasis en bloc. Inclusion of the cervical plexus, parts of the paravertebral musculature, previous exposure of the common carotid artery, vagus nerve and phrenic nerve. Securing the nerves. Cranial release of the muscle hard on the mastoid. Free conditions here. The accessorius nerve is not exposed in the case of complete infiltration. Cranial infiltration of the caudal parotid pole circumscribed, therefore resection of the free caudal parotid pole, here close relationship to the oral branch, which however is only partially visualized, visualization of the digastricus venter posterior muscle, which is also free. In the area of the intermediate tendon or middle area, infiltration or direct contact with the tumor is clearly visible. Exposure of the internal jugular vein cranially. Deposition after double ligation. The metastasis can now be isolated to the carotid sheath, the digastric muscle as well as the area of the paralaryngeal muscles, here direct contact or tumor breakthrough with contact to the metastasis, therefore the metastasis is marked in this area. Cervically, the tumor infiltrates the entire lateral wall of the pharynx in the direction of the hyoid. Level 1b had already been cleared previously. At least one overlying lymph node can be seen macroscopically. Resection of the submandibular gland with partial exposure and protection of the branch of the mouth. The infiltrated digastric muscle shows a tissue turf, circumscribed to the connective tissue of the carotid artery, in the area of the bulb and the division site as well as circumscribed to the prelaryngeal musculature. Therefore, the carotid artery is now completely skeletonized far to the cranial side. No evidence of infiltration of the carotid artery. In case of hyoid infiltration, visualize and release the hyoid. Dissection median, with dissection rather adherence of the tumor than direct infiltration. Nevertheless, take along a good half of the hyoid after triggering. Carefully enter the vallcula, but the tumor can be felt immediately. Therefore widen the safety distance. Enter the pharynx. It can be seen that a tumor cone is directly approaching the petiolus, therefore a good 2/3 resection of the epiglottis. Removal of the hyoid bone as described above, removal of the pre-epiglottic fat, the tumor ends caudally just before the entrance to the piriform sinus. Cut around the tumor with a safety margin. The cone in the area of the epiglottis is seen before dissection as the cause of the circumscribed breakthrough in the area of the prelaryngeal musculature. Careful removal of the musculature, but in some cases complete basal resection through the neck resectate. Now successive exposure of the tumor. Removal of approx. 1/3 of the base of the tongue. Here there is a good 1 cm safety margin on palpation. Resection via the posterior floor of the mouth. In the case of adherence as described above, incision of the periosteum in the area of the dorsal mandibular branch, removal of the periosteum and completion for transoral removal of the tumor, in this case, as described above, no periosteal breakthrough and complete removal. Gradual release of the tumor after securing the carotid artery. A clear infiltration of the hypoglossal nerve was already evident beforehand. Separation of the hypoglossal nerve and, in the case of prolonged, clear macroscopic infiltration, removal of a marginal sample in the area of the hypoglossal nerve. This is shown to be tumor-free in the frozen section diagnosis. In the area of the posterior pharyngeal wall, the tumor just reaches the midline. Here also resection with a safety margin, partial entrainment to the further safety margin of the prelateral vertebral musculature, but no injury to the prevertebral fascia. The tumor is now isolated cranially to remnants of the pterygoid musculature. Separation of the remains of the pterygoid musculature. Clear infiltration here. A resection of all muscle stumps is performed in the area of the pterygoid musculature, this is done to extend the safety distance to the definitive histology and covers the entire infiltrated pterygoid musculature. Here, however, also on the preparation macroscopically in sano. On the specimen, the tumor is now macroscopically and palpatorily resected in sano on all sides except for the previously described areas, which have broken through transcervically and are covered here by the neck dissectate or post-resectate. Macroscopically and palpatorily rather scarce areas are marked with sutures, the preparation is completely sent for frozen section diagnostics. Confirmation of the transcervical tumor extension, but mucosal area and also in the area of the pterygoid muscles as well as in the area of the base of the tongue and pharynx on specimen R0 situation. Therefore, hemostasis after careful wound inspection. Measurement of the defect. There is an extensive defect with an almost total soft palate defect extending to the hard palate, approx. 2/3 resection of the oropharynx, 1/3 resection of the base of the tongue, 2/3 resection of the epiglottis and complete resection of the vallecula. Measurement of a graft measuring up to 17 x 8.5 cm in total with corresponding configuration for the soft palate and the base of the tongue. Due to the extent of the graft, a decision is made to harvest an anterolateral thigh graft. Parallel to this, the neck dissection of the left side is performed. For this purpose, a skin incision is made on the anterior edge of the sternocleidomastoid muscle. Separation of skin and subcutaneous tissue. Exposure and dissection of the platysma. Exposure and preservation of the external jugular vein. 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 and careful protection of the superior thyroid artery, the hypoglossal nerve and the cervical sinus. Exposure and preservation of the facial vein. Dissection of the internal jugular vein. Some macroscopically clearly conspicuous lymph nodes, therefore clinical confirmation of contralateral metastasis, but no perinodal growth here. Exposure of the accessorius nerve, evacuation of the accessorius triangle with careful protection of the nerve. Release of level 5 with careful protection of the cervical plexus branches. Careful wound inspection. Irrigation of the wound. Insertion of a 10-gauge Redon drain and careful two-layer wound closure. For elevation of the anterolateral thigh graft after identification of the landmarks and the perforator line, doppler sonographic identification of the skin perforator approx. 4 cm cranial to the midline. Identification of a small secondary perforator in the area of the midline. Configuration of the graft under pedicle positioning. First enter medially. Cut through skin and subcutaneous tissue. Exposure of the sartorius muscle. Exposure and reliable identification of the rectus femoris muscle. Strictly subfacial dissection, exposure of the vascular pedicle. The division of the lateral circumflex artery into 1 caliber-equal ramus descendens, ramus obliquus and transversus can be seen. The main perforator clearly originates from the oblique branch. The secondary perforator is most likely from the descending branch. Therefore, first visualize and dissect both branches. Dissection of the vessel now shows that both branches open separately into the lateral flexure of the circumflexus. Pronounced venous siphon. After reliable identification of the perforators, complete cutting of the graft and execution of the relief incision. Expose the fascia lata, cut through the fascia lata. With a very strong thigh overall and therefore a strong graft, it becomes apparent that the secondary perforator in the area of the future soft palate can only be utilized with the inclusion of muscle. Therefore, the secondary perforator is not used. The main perforator is purely fasciocutaneous. Installation on the main perforator after elevation of the fascia lata. With excellent flap vitality, placement of the descending ramus after ligation. Insulation on the ramus obliquus, vessel preparation. Dissection of a strong vein after dissection of the vascular findings. With excellent vitality, removal of the graft. Careful wound inspection. Wound irrigation and, if the wound is dry, strong and multi-layered wound closure after insertion of two 10-gauge Redon drainage tubes. The graft is now inserted. Multiple sutures are placed transcervically and transorally. Insertion of the graft. Due to the thickness of the graft and the resection up to the hard palate in the area of the soft palate, the suturing conditions are significantly more difficult and the adaptation conditions are suboptimal. Subsequent sufficient soft palate closure. A small dehiscence must be left medial to the hard palate in the event of increased tension or lack of mucosa, but this should granulate without problems. Otherwise, successive insertion of the graft and overall more difficult conditions, but overall good fit. Regular and sufficient insertion with subsequently stable and dense conditions. Meticulous insertion in the area of the vallecula and the pharyngeal wall. In the case of dense conditions, the flap vascular pedicle is now conditioned. This shows a strong vein with a relatively slender artery, therefore dissection of the superior thyroid artery, distal placement. Furthermore, caliber advantages in the area of the superior thyroid artery. Therefore somewhat more difficult suturing conditions. Finally, however, good adaptation with 8.0 Ethilon with immediate regular venous return. Good pedicle pulsation. The first step is to condition the facial venous stump, but this is clearly thrombosed and with clear endothelial damage and a stump very close to the internal jugular vein, no further preparation is possible here, so the superior thyroid vein is conditioned. Regular flow conditions here. Measurement of a size 4.0 coupler. Problem-free insertion of the venous anastomosis, regular pulsation immediately after reopening the clamps and excellent enoral flap vitality. Careful handle positioning, wound inspection and, in dry wound conditions, insertion of two 10-gauge Redon drains in the case of a cervical paravertebral defect and subsequent careful two-layer wound closure. During wound closure, final multiple inspections and completion of the procedure with excellent flap vitality. Finally, detailed consultation with the anesthesia department and transfer of the patient to the intensive care unit on mechanical ventilation. Note: The patient received intraoperative antibiotic prophylaxis with Unacid 3 g, please continue this for an initial 24 hours. Conclusion: Extensive intraoperative R0 resected cT4a cN3 oropharyngeal carcinoma on the right with growth per continuitatem into the soft tissues of the neck, clinical metastasis on the right side up to level 5b. Due to the diffuse growth of the primary towards the soft tissues of the neck, an Rx situation should be discussed here. Adjuvant RCT urgently required. Please perform meticulous postoperative flap monitoring by enoral inspection. If the flap is still viable, an X-ray mucosa should be taken on the 10th postoperative day. Due to the extent of the tumor, significantly prolonged swallowing rehabilitation is to be expected.