At the beginning of the operation, after induction of anesthesia by the anesthesia colleagues, a pharyngoscopy was performed to determine the exact extent of the tumor. An exophytic tumor was found in the area of the left tonsillar lobe, which almost filled the tonsillar lobe, but without significant involvement of the posterior pharyngeal wall or extensive transition into the soft palate. The tumor extends over the glossotonsillar groove into the base of the tongue and the edge of the tongue if the posterior floor of the mouth is intact. The edge of the tongue is clearly affected on the free lateral surface. Exulcerated tumor here. Anteriorly only the marginal area is infiltrated. The width of the tumor increases dorsally. Significant infiltration of the base of the tongue. Almost half of this is palpatorily infiltrated. Inspection of the vallecula. This is again free of tumor, as is the lateral wall of the pharynx. Palpatorily clear cervical lymph node metastasis as a conglomerate on the left. The rest of the pharynx and the endolarynx are clear. PEG tube was therefore initially inserted. Insertion with the gastroscope under laryngoscopic control. Problem-free pre-scanning into the stomach. After good diaphanoscopy, problem-free puncture of the stomach and insertion of the PEG tube using the usual suture pull-through method. Subsequent repositioning of the patient. First start with the enoral resection. Here, the tumor is first cut around with the electric needle. Then further dissection using the dissection technique. The left edge of the tongue is released while maintaining a safety distance of approx. 1.5 cm. Resection up to the edge of the tongue. Release of the tumor and lateral displacement, additional release of the part of the tonsil region. Deposition hard on the uvula, taking the anterior palatal arch with it. Resection up to the alveolar ridge while maintaining the safety distance. Partial removal of the pharyngeal muscles. Subsequent partial exposure of the soft tissue of the neck. Macroscopically, complete in sano conditions on all sides, as well as in the area of the sedimentation margins in the area of the mucosa. Release of the glossotonsillar groove and circumscribed involvement of the posterior floor of the mouth. Here, the tumor moves slightly into the depth, also poor overview in the area of the base of the tongue, therefore no further transoral resection is performed here. The area resected so far is completely covered with margin samples and diagnosed as in sano in the frozen section diagnostics. Now reposition for neck dissection on the left. To do this, make a curved skin incision on the anterior edge of the sternocleidomastoid muscle. Cut through the skin and subcutaneous tissue. Exposure and dissection of the platysma. Creation of a platysma flap. Exposure of the anterior border of the sternocleidomastoid muscle. This is partially displaced. Free preparation of the muscle. When exposing the muscle, a clear infiltration can be seen approximately in the middle of the course. Therefore, after exposing the omohyoid muscle, the submandibular gland and the digastric muscle, the sternocleidomastoid muscle is exposed caudally and later cranially on the mastoid. After dissection of the borders, the internal jugular vein is now exposed. This shows that the metastasis clearly infiltrates the venous angle. Longer infiltration of the internal jugular vein and the outlet of the facial vein. Careful release of the metastasis in the area of the veins to preserve the superior thyroid vein and the cranial facial drainage. After removal of the internal jugular vein and mobilization of the metastasis, which is also partly located in the cervical plexus, a further extensive metastasis of approx. 4 x 5 cm is now visible behind the internal jugular vein. This infiltrates the internal jugular vein at the back, hence the caudal separation of the internal jugular vein. Exposure and preservation of the common carotid artery and the vagus nerve. Caudal evacuation of level V, also here several nodes, so that level V b is also evacuated. Here without visible visualization of the thoracic duct, but lymph leakage. Selective bipolar coagulation, if lymph leakage persists, later repositioning of the tissue and in case of incomplete reduction, application of TachoSil and TaboTamp. Evacuation and completion of the neck preparation with evacuation of level I b and level II a. The accessorius nerve was already resected in the 1st metastasis. After exposure of the entire digastric muscle, resection of the muscle, careful removal of the submandibular gland from the surrounding tissue, carefully preserving the cranially preserved facial branches. First expose and preserve the facial artery. This and the lingual artery are later dissected and removed. After releasing the submandibular gland with uncinate process from the floor of the mouth, tunneling to the resection area. Partial resection of the mylohyoid muscle with widening of the pharyngotomy. Entering the posterior floor of the mouth. Widening of the pharyngotomy and successive release and mobilization of the tumour. The entire soft tissue covering the outside of the tumor in the area of the floor of the mouth and cervically is removed. Exposure and exposure of the base of the tongue after extending the pharyngotomy caudally. Now a good overview and macroscopic complete resection of the base of the tongue. Due to the alteration and manipulation of the tissue, only a thin ridge remains between the tumor part in the tonsil region and the tumor part at the base of the tongue after excision of the tumor. The site is marked with a corresponding suture and the tumor is sent for definitive histology. This is followed by the taking of marginal samples, completely covering all edges. These are diagnosed in the area of the base of the tongue caudally, close to the tumor, with discrete residual infiltrates. Due to the thickness of the post-resectate, however, a minimum safety margin of 9 mm is required here. Otherwise, all other tumor margin samples are clear, so that an R0 situation can be assumed here. Now measure a lobulated graft measuring approx. 13 x 9 cm in total. Turn to graft harvesting from the right thigh. Here, after identification of the main perforator and 3 further secondary perforators by Doppler sonography, marking of the graft. Medial incision. Cut through the skin and subcutaneous tissue. Exposure and secure identification of the rectus femoris muscle. Slinging of the muscle. Strictly subfascial dissection. Identification of the pedicle vessel. Performing an extension incision. Further dissection of the pedicle and isolation. Release of the fascia above the intermedius portion. Complete cutting of the graft. Removal of the fascia lata. Caudal fascio cutaneous graft. Most of the perforators run with a small intramuscular course. Therefore use of a muscle cuff. Careful protection of the perforators. Isolation on the vascular pedicle and preparation of a strong artery and two draining veins with good confluence if the flap is properly vitalized. Deposition of the graft. Careful wound inspection. Insertion of a 10-gauge Redon drain and careful, two-layer wound closure with local balancing plasty in the area of excess skin. Neck dissection on the right side and plastic tracheotomy were performed at the same time. Neck dissection on the right: skin incision on the anterior edge of the sternocleidomastoid muscle. Dissection of skin and subcutaneous tissue. Exposure and dissection of the platysma. Exposure of the sternocleidomastoid muscle, the omohyoid muscle and the digastric muscle after exposure of the submandibular gland. Free preparation of the internal jugular vein. Preservation of the middle thyroid vein and the facial vein. Removal of the anterior neck preparation with careful protection of the hypoglossal nerve and the superior thyroid artery. Exposure of the accessorius nerve. Evacuation of the accessorius triangle with careful protection of the nerve and evacuation of level V with protection of the cervical plexus branches. Finally, wound inspection and, if the wound is dry, insertion of a 10-gauge Redon drain and two-layer wound closure. Tracheostomy: Insertion approx. 1 cm below the tracheostoma. Cut the skin and subcutaneous tissue horizontally. Exposure and ligation of the anterior jugular vein. Exposure of the infrahyoid musculature. Entering the linea alba. Exposure of the anterior surface of the cricoid cartilage. Exposure of the anterior surface of the trachea. Exposure and transection of the thyroid isthmus after perforation. Complete visualization of the anterior surface of the trachea. Insertion between the 2nd and 3rd tracheal ring. Creation of a broad-based pedicled Björk flap and careful incision of the tracheostoma on all sides. In the case of small dehiscence for neck dissection with extensive resection, the paralaryngeal muscles are later adapted with the subcutaneous tissue so that reasonably tight conditions can be created here. The patient is then reintubated, initially onto an 8 mm tube and later onto a cannula with an inner core. This succeeds without any problems. Suture fixation of the cannula. The transplant is then inserted. This is done step by step transorally and transcervically. Gradual incorporation of the graft. This works well with a good fit. Good volume filling in the area of the base of the tongue. Intact conditions. The resection area extends caudally into the vallecula and in the area of the pharynx up to the entrance of the piriform sinus. After complete incision, dissection of the flap vascular pedicle. Thrombosis of the partially detached superior thyroid artery is now evident. Despite cutting back the artery, no equivalent blood flow and clear thrombosis. Therefore ligation. Also thrombosis of the detached facial and lingual arteries. Dissection of the transverse cervical artery. This has a widely tortuous course. Free dissection of the artery, providing good opportunities for rotation. Perform the arterial anastomosis with 8.0 Ethilon. This works very well. Tight conditions and immediate venous return flow. Now first dissection of an upper thyroid vein. This now shows clear thrombosis. Repeated irrigation with heparin does not lead to any relevant reflux. The facial vein is now dissected in the caudal direction. There is a branched course with palpatorily clear flow. After opening, the flow is regular so that this vein can now be used for connection after maximum mobilization of the artery. Performing the venous anastomosis with Coupler 3.5, which works well. Moderate tension conditions in relation to the arterial anastomosis. Regular flap vitality on inspection. Final inspection of the wound surfaces. Despite all the measures in level V b, there is still moderate lymphatic leakage after the above measures have been carried out, here with TachoSil and TaboTamp. Due to the arterial anastomosis via the arteria transversa cevicis, no further transpositions were necessary. Insertion of a guided 10 Redon drain and careful, two-layer wound closure. At the end of the operation, regular flap vitality and transfer of the patient to the intensive care unit on mechanical ventilation. Conclusion: Intraoperative R0-resected cT3 cN2b oropharyngeal carcinoma on the left with approx. 2/3 resection of the base of the tongue. Due to the extensive metastasis and aggressive local growth, adjuvant therapy is certainly urgently required. Please leave the cannula in place as long as possible postoperatively, for approx. 6 to 7 days, if the tracheostoma is clearly close to the left side of the neck with complex anastomosis. Depending on the left cervical lymph leakage, please start with conservative treatment. Strict avoidance of pressure bandages. Leave the 10 Redon drain in place until the flow rate is significantly reduced. Pull the Redon drainage by the surgeon. If the wound is healing properly, perform an X-ray gruel on the 10th postoperative day. Due to the extent of the tumor, the reconstruction and the patient's constitution, prolonged swallowing rehabilitation is to be expected. Depending on recovery of the general condition, planning of thoracic surgery to repair the round lung tumor.