First pharyngoscopy and laryngoscopy: The exophytic tumor is seen in the tonsillar lobe area extending from the palatine arch down to the hypoharyngeal entrance, involving the base of the tongue, on the edge of the tongue on the left side, tumor extends medially over the vallecula and lingual epiglottis to just above the midline, here in the supraglottic area. Base of tongue palpatorily affected up to the midline. Indication for surgery with flap coverage confirmed. Now repositioning of the patient. Injection not possible due to the cardiologic situation. Start with extended radical neck dissection on the left: Typical skin incision in front of the sternocleidomastoid muscle. Exposure of the anterior border of the sternocleidomastoid muscle. This shows that the lymph node package has infiltrated the muscle in the middle and cranial area. The muscle is therefore removed cranially and caudally and also resected. Further dissection shows infiltration of the internal jugular vein, which is separated slightly below the exit of the inferior thyroid and ligated twice. However, the external jugular vein was preserved during dissection, and a supraclavicular vein and an additional outlet from the internal jugular vein, which could be used as a vascular anastomosis, can also be seen in the lower area. Further dissection shows infiltration of the lymph node conglomerate in the submandibular gland, hence resection of this gland and the caudal parotid pole as well as the digastric musculature. There is also infiltration of the external carotid artery. This must be placed just above the bulb and is supplied here by means of bypasses. The facial artery, lingual artery, superior thyroid artery and all other cranial ascending branches up to the superficial temporal artery must be resected and ligated. The external carotid artery is ligated twice cranially. It becomes apparent that the tumor is in contact with the primary tumor, so that per continuitatem growth at the level of the hyoid bone and in the area of the resected external carotid artery must be suspected. This is followed by repositioning for first transoral and then transcervical combined resection of the oropharyngeal carcinoma. First insertion of the tonsillar blocker from the transoral side, alternating with oral blockers. Tongue ligation. Tumor is incised on all sides with a safety margin of at least 1.5 cm to 2 cm. This involves resection of the palatal arch from the uvula to the left, all tissue up to the lower jaw, whereby the periosteum is pushed away from the lower jaw. Pterygoid muscles are resected per continuitatem through the wall. The internal carotid artery is checked from the side here. The posterior wall of the oropharynx is resected almost to the middle. The posterior half of the tongue is initially resected superficially and only later in the tongue base area beyond the midline. The mobilized specimen is finally pulled through transcervically and the mucosa is resected under visualization up to the piriform sinus entrance in the oropharyngeal side wall area. The entire vallecula, the epiglottis and the base of the tongue are resected medially until a residual portion of approx. 25 % remains. This is still well supplied with blood. On the opposite side, the more cranial base of the tongue is still preserved and the caudal part is resected together with the vallecula. Resection ends at the beginning of the supraglottic area after removal of the epiglottis. The entire preparation and a marginal sample from the palatal arch and from the area of the base of the tongue and vallecula on the right side are sent in. Here the specimen on all sides in healthy tissue, including basal, cranial and caudal as well as the marginal specimens are also tumor-free. The intraoperative situation is therefore R0. Neck dissection now follows on the right side. Skin incision in the typical manner, dissection of the fat lymph node package of the sternocleidomastoid muscle. The lymph node is adherent to the facial vein and internal jugular vein, but can be dissected here while preserving the vessels. Exposure of the omohyoid muscle and digastric muscle. Final exposure of the cervical vascular sheath, vagus nerve, accessorius nerve and hypoglossus. Development of the dorsal neck preparation while preserving the branches of the cervical plexus. Subsequent development of the anterior neck preparation. The result is a neck dissection level II to V on the right side and Ib to V on the left side. Now the tracheostoma is created in the typical manner. Longitudinal section between the neck sections. Depiction of the trachea. Entering the 2nd/3rd intercartilaginous space. Small, broadly pedunculated Björk flap. This is epithelized in a typical manner. Re-intubation and insertion of laryngectomy tube. The defect is then covered using a pectoralis major flap: The planned defect coverage using a free flap proves to be unfeasible intraoperatively. The remaining residual stump of the left external carotid artery shows clear calcific plaques on palpation. If the patient has had an apoplexy, clamping without an increased risk of reapoplexy does not make sense here. Venous anastomosis on the left via the external jugular vein is possible. However, the arterial connection on the same side is missing. The evaluation of the vessels in the supraclavicular region also shows no corresponding possibilities for a vascular connection. ........................ The right side shows an external carotid artery, which is too short for a primary anastomosis of the ALT and also too small for a possible interposition. The first outlet appears to be a thyro-lingual artery. The transection of the lingual artery is not possible due to the previous resection of the opposite side. This also rules out the external carotid artery as an option for arterial anastomosis. The only remaining option is to use a pectoralis major flap to cover the defect. The patient is therefore repositioned. Sterile covering of the entire thoracic area up to the upper abdomen. After measuring the length of the flap pedicle and the size of the skin island, the island is marked according to the extent and shape of the defect. A subfascial skin bridge is then created from the neck area to the lower end of the marked deltopectoral flap, which is not lifted distally. Then expose the pectoralis major muscle and expose the vascular pedicle. The flap is then cut to the appropriate size and length and securing sutures are placed. The flap has a length of 11 1/2 cm and a width of 6 cm in the distal area and 9 cm in the proximal area. Successive development of the flap on its muscle pedicle including the vascular nerve bundle up to the clavicle. The flap is then pulled under the skin bridge. Insertion of the flap into the oropharyngeal defect. The flap is first sutured cranially, including the palatal arch. Caudally, the flap extends to the piriform sinus entrance, it then swivels towards the supraglottic area. The skin island is sutured directly supraglottically to the thyroid cartilage. Complete low-tension closure of the defect. Subsequent layer-by-layer closure of the thoracic wound after skin mobilization, which is successful without tension. Skin closure after extensive hemostasis with insertion of 2 Redon drains. On the left cervical side, tension-free closure over the pedicle after radical neck dissection with insertion of 2 Redon drains. On the right, the wound is closed with the insertion of a Redon drain. An 8-gauge tracheostomy tube is inserted into the tracheostoma. The patient is admitted to the intensive care unit postoperatively and ventilated. Antibiotic treatment, which was started intraoperatively, is continued with Unacid for one week. In the case of circulatory instability or previous cardiological illness and due to the use of Plavix or previous heparinization, the operation was characterized by a diffuse bleeding tendency in the advanced course. Factor replacement and preservatives were necessary. Post-operative nutrition via the inserted PEG for 10 days, followed by gruel and then, if necessary, diet reconstruction. Overall cT4a cN2c findings and continuous growth on the left. Postoperative RCT recommended if the patient's condition permits.