Introductory consultation with the anesthesiologist. First pharyngoscopy and laryngoscopy: The exophytic tumor is seen, which begins at the right tonsillar lobe and extends down the glossotonsillar groove into the base of the tongue. Palpatorily just reaching the middle of the tongue base. Caudal to the entrance to the hypopharynx. Thus confirming the indication for surgery. Dictation <CLINICIAN_NAME>: First neck dissection of the left side. Curved skin incision along the anterior edge of the sternocleidomastoid. Dissection through the subcutaneous tissue and platysma. Exposure of the anterior edge of the sternocleidomastoid muscle, the omohyoid muscle, the posterior digastric venter muscle and also the accessorius nerve. Displacement, neurolysis and re-embedding of the accessorius nerve. Subsequent dissection of the internal jugular vein from caudal to cranial. Isolation of the cervical vascular sheath laterally and formation of the lateral neck preparation from cranial to caudal while sparing the accessory nerve and the plexus branches. Turn to the medial neck preparation. Dissection of the submandibular gland, the facial vein, the hypoglossal nerve and protection of the latter. Displacement, neurolysis and re-embedding of the hypoglossal nerve. Subsequent resection of the medial neck preparation while sparing the structures mentioned. At the end of the operation, placement of a Redon drain and two-layer wound closure using subcutaneous and skin sutures. Pressure bandage. Neck dissection of the right side. Level II shows clearly enlarged lymph node metastases. Otherwise identical procedure. Dissection along the anterior edge of the sternocleidomastoid. Identification of the omohyoid muscle, the posterior digastric venter muscle and the accessorius nerve and dissection of the internal jugular vein from caudal to cranial. Displacement, neurolysis and re-embedding of the accessorius nerve. The metastases can also be removed from the vessel. Subsequent formation of the lateral neck preparation while sparing the accessorius nerve and the plexus branches. Exposure, displacement, neurolysis and re-embedding of the hypoglossal nerve. Then resection of the medial neck preparation while sparing the hypoglossal nerve and the facial vein. Creation of a Redon drainage, two-layer wound closure. Pressure dressing. Transition to tracheotomy: X-shaped skin incision. Dissection through the subcutaneous tissue and platysma. Spreading of the pretracheal muscles. Identification of the cricoid cartilage. The thyroid isthmus is revealed very far caudally and is only bipolized. Then open the trachea between the 2nd and 3rd tracheal ring. Formation of a Björk flap and epithelialization of the flap using six tracheostomy sutures. PEG placement: Flexible esophagogastroscopy. After positive diaphanoscopy, placement of the PEG tube in the typical manner using the thread pull-through method. Dictation <CLINICIAN_NAME>: Subsequent combined transoral transcervical tumor resection: First dissection of the pharyngeal wall and dissection of all vessels from the outside. Cut around the tumor from the inside transorally as far as possible. This can be done cranially and along the lower jaw. Controlled dissection from the inside to the outside. Inclusion of the entire pharyngeal wall. Extraction of the tumor into the soft tissues of the neck. Further resection with a safety margin of at least 1.5 cm on all sides. The tonsil lobe, pharyngeal side wall, glossotonsillar groove and base of the tongue up to half as well as parts of the vallecula and the pharyngeal wall up to the hypopharyngeal entrance were removed. As part of the resection, the submandibular gland was also resected as well as parts of the external tongue musculature with parts of the hyoid bone. The tumor is thread-marked after resection. Marginal samples are taken from the hypopharynx and from the area of the pharyngeal wall extending to the uvula, from the base of the tongue, from the body of the tongue and a marginal sample from the alveolar ridge, which extends to the base of the tongue via the glossotonsillar groove. No evidence of carcinoma in any of the marginal samples. No high-grade dysplasia. Therefore R0 situation. After measuring the defect in its three-dimensional dimensions, removal of the radial lobe on the left forearm: Flap length maximum 10 cm, width maximum 7 cm. Flap shape is adjusted to the defect towards the floor of the mouth and base of the tongue. First cut ulnarly and lift subfascially. The ulnar artery is carefully spared. The incision is then extended into the antecubital fossa. First expose the superficial venous system and dissect it. Then expose the pedicle under the brachioradialis. Then incision of the flap from radial and subfascial elevation. The antebrachial cutaneous nerve is carefully spared. Caudal clamping of the radial artery. Saturation always at 100%. After approx. 15 minutes without a drop in saturation, the radial artery is removed. This is stitched and ligated with 4.0 Ethilon single button sutures. This is done both proximally and distally. Lift the flap subfascially with the pedicle and superficial venous system successively up to the antecubital fossa. Outgoing vessels are either ligated, bipolar coagulated or treated with a clip. Exposure in the antecubital fossa, connection between superficial and deep venous system. Exposure of the radial artery. The interosseous artery is first clamped off and can be supplied with clips and cut after a constant saturation of 100%. No confluence of the radial artery can be shown. Two outlets from the area of the cephalic vein can be visualized, which can be considered as connecting vessels. The flap is then removed. The veins are ligated. The artery is treated with 6.0 Vascufil stitches. Careful hemostasis is then performed. Removal of an appropriately sized piece of full-thickness skin from the groin area. After skin mobilization, the skin is closed in several layers with the insertion of a Redon drain. The full-thickness skin is inserted into the forearm defect after appropriate thinning. Fixation using 4.0 Ehtilon sutures. Skin closure up to the crook of the elbow in layers. Application of a hydrogel/Mepilex dressing. Application of Wölkchen compresses on top. Wrapping in absorbent cotton. Application or adjustment of a Kramer splint and wrapping of the arm in a functional position using an elastic bandage on the Kramer splint. Saturation always at 100%. Positioning of the arm. Insertion and suturing of the flap into the pharyngeal defect: passing the stem through to the soft tissues of the neck. Successive suturing of the flap into the defect using 3.0 Vicryl single button sutures according to the three-dimensional arrangement without tension. Suturing is performed partly transorally, partly transcervically and partly with the sutures in place. Complete tension-free closure. Subsequent conditioning of the flap vessels and conditioning of the connecting vessels. The lingual artery is selected. It is conditioned and anastomosed to the radial artery using 8.0 Ethilon single-button sutures. After opening the clamp, good arterial flow, good venous return. Subsequent conditioning of the larger vein from the area of the cephalic vein. Conditioning of the facial vein. Selection of a 3.5 mm coupler. Anastomosis of the veins without difficulty using a coupler. Good venous return after opening the clamps. Positive smear phenomenon. The other outlet on the cephalic vein is clipped. Careful hemostasis in the entire neck area. Irrigation. Wound closure in layers with insertion of a Redon drain in both sides of the neck. The inserted 8 mm tracheostomy tube is fixed with a suture. The site intended for Doppler control is marked with suture. Final transoral check shows well perfused flap. The procedure is completed without complications. Patient goes to the intensive care unit for postoperative monitoring. Please continue the antibiotic treatment with Unacid started intraoperatively for at least 2-3 days postoperatively. Feeding via the PEG tube for at least 10 days, then gruel and, if necessary, diet build-up. Continue intraoperative heparin therapy using a 500 I.U. per hour perfusor for at least 5 days postoperatively. Flap control transorally or by means of Doppler according to scheme. 30 body elevation. Total cT3 cN2b oropharyngeal carcinoma on the right. Presentation of the patient at the interdisciplinary tumor conference to determine the adjuvant therapy according to the final histology. Final consultation with the anesthesia department.