After intubation by the anesthesia colleagues, inspection of the tumor region with the mouth retractor and the small bore tube. Starting in the area of the soft palate on the right, an ulcerating, rather flat tumor is seen, which grows on the right side to the parauvular region and consumes the tonsil region. The alveolar ridge is free on palpation. The change extends over the glossotonsillar groove to the tongue, but does not infiltrate it; growth continues caudally over the lateral pharyngeal wall into the piriform sinus entrance. Here, further growth in terms of longitudinal extension, therefore a clear cT3 finding. After partial laryngectomy with residual epiglottis and tilted laryngeal skeleton, otherwise clear conditions. No evidence of laryngeal infiltration. Initially start with transoral resection. Insertion of the McIvor blade. Resection of the tumor with a safety margin of at least 1 ˝ cm. The uvula is removed in the area of the soft palate. Subtotal resection of the soft palate. Removal of the entire tonsil lobe and removal of the glossotonsillar groove. Macroscopically in sano on all sides. No evidence of basal growth in depth. Therefore, enoral sampling in the area of the soft palate and at the buccal margins. These are assessed as tumor-free in the frozen section diagnostics. Now repositioning for transcervical implication of the resection, preoperative ycN0 neck status. Submandibular skin incision at the anterior edge of the sternocleidomastoid muscle. Cut through the skin and subcutaneous scar plate. Careful and laborious dissection. Exposure of remnants of the sternocleidomastoid muscle. Pronounced scarring and blocking. Exposure of the internal jugular vein. Exposure of the common carotid artery. A superior thyroid artery can no longer be visualized. Also anteriorly scarred conditions without residual neck preparation. In level III and, after exposure of the submandibular gland and the extremely scarred digastric muscle, removal of a small amount of scar and fatty tissue. These are sent as a neck resectate for definitive histology. Exposure of the hypoglossal nerve. Exposure of the lingual artery and the ascending pharyngeal artery and exposure of the superior laryngeal artery. An accessorius nerve can no longer be visualized. Now release the digastric muscle. Exposure of the hyoid. Exposure of the thyroid cartilage horn. Now entering the hyoid laterally on the right. Very thin conditions here. Direct transition from scar tissue to enoral and here already conspicuous tissue. When the pharyngotomy is widened, contact is made with the pharyngeal tumor extension in the area of the right hypopharynx. Therefore, the hyoid is now removed. Widening of the pharyngotomy. Now a good overview of the tumor. Inclusion of the vallecula, epiglottis margin and a tongue base cuff and completion of the resection area towards the glossotonsillar groove. Now resect the pharynx to just before the middle of the hypopharynx and connect the resection area to the posterior pharyngeal wall. Now continue to expose the carotid artery and remove the entire soft tissue block subcutaneously. The tumor is now completely resected. In the area of the tumor injury during the pharyngotomy, the tumor was removed in a circumscribed and controlled manner for a better overview. Except for the caudal tumor cone, the R2 situation is marked here. Complete control of the basal tissue by exposing the common carotid artery and including the hyoid as well as the thyroid cartilage horn on the right. Inclusion of the entire tissue block. Cut around the residual tumor cone, which is located in front of the piriform sinus entrance. Finally, remove a strip of mucosa in the area of the caudal pharynx, towards the hypopharynx and the posterior pharyngeal wall, leaving a clear safety margin. All resectates are sent for frozen section diagnostics. Here, the area of the main specimen is clear except for the marked caudal margin, but with a narrow resection distance to the basal side. As already described, the entire cervical tissue was resected here. The caudal tumor cone also shows tumor-free margins in the resection area. The post-resectate is completely tumor-free. Therefore, due to the cervical resection of the wound bed or tumor bed and the free mucosal margins, a definitive R0 situation can be assumed. An approx. 2-3 mm thick vein accompanying the occipital artery was already secured in level IIa. Sufficient drainage to the mastoid was ensured. The prerequisites for a microvascular connection are therefore present. Due to the patient's slender proportions and the fresh humerus fracture, the decision was made to cover the defect using an ALT graft from the right. After marking the landmarks, doppler sonographic identification of two main peforators. Marking of a graft measuring 12 x 5.5. Medial incision. Separation of skin and subcutaneous tissue. Exposure of the fascial plane. Exposure of the rectus femoris muscle. Clamping of the muscle cord. Subfascial dissection. Exposure of the vascular pedicle. It becomes apparent that both the ramus desendens and the ramus oblique of the lateral circumflex perforators are branching off into the graft. It was therefore decided to take both branches. Further exposure of the vascular pedicle. Visualization of the confluence of both branches. A common arterial inflow can be visualized. Visualization of the perforators, these are well developed. Complete cutting of the graft. Cut through to the fascia lata. Taking along the fascia lata and salvaging the graft while taking along a sufficiently protective muscle cuff around the perforators. Careful protection of the perforators. Isolation to the exposed artery and a strong vein and, with excellent flap perfusion, placement of the graft. Careful wound inspection, dry conditions after ligation of vascular stumps, dry conditions after wound irrigation with Ringer's solution. Insertion of a 10 Redon drain and careful, two-layer wound closure. Now successive placement of 3/0 Vicryl mucosal sutures transcervically. Then pull the graft through enorally. Here, advance in the area of the posterior palatal arch or the soft palate dorsally and towards the nasopharynx. Incorporation of the graft enorally and complete suturing over the transcervically placed sutures. Finally, tight conditions. Good graft fit. Now prepare the lingual artery for vascularization. However, this is not continuous. No flow here even after shortening. Therefore clipping of the artery. Now expose the ascending pharyngeal artery. This shows a regular, good flow. Suturing conditions are now much more difficult due to the course of the vessel. Careful vessel position. Performing the vascular suture with 8/0 Ethilon. After reopening the Acland clamps, initially lack of perfusion, but excellent flow after repositioning the flap and handle. Immediate venous return and excellent flap vitality enorally. Then preparation of the occipital vein. Measurement of a 2.5 mm coupler, limited by the diameter of the occipital vein. Perform the coupler anastomosis. After reopening the clamps, immediate good perfusion of the graft and regular enoral vitality. Control of the course of the pedicle. The venous anastomosis now results in a tortuous but stable course without any significant tendency to kink. Positioning of the muscle cuff and careful, two-layer wound closure. Insertion of a flap. Control of the graft at the end of the operation. Excellent flap vitality. Transfer of the patient to the intensive care unit. A tracheotomy had already been performed previously. For this, a skin incision was made approx. 1 cm below the cricoid cartilage and a small access was made to avoid connecting the two wound cavities. Exposure of the cricoid cartilage and the anterior surface of the trachea. Insertion between the 2nd and 3rd tracheal ring. Insertion of a broad-based pedicled Björk flap. Incision of the Björk flap and the trachea. Performance of the mucocutaneous anastomosis. Subsequent problem-free reintubation to an 8-gauge Rüsch cannula. Conclusion: Intraoperative R0-resected ycT3 ycN0 oropharyngeal carcinoma on the right. Postoperatively, please monitor the flap minutely. Postoperative X-ray gruel swallow on the 10th postoperative day due to pre-irradiation. After receiving the definitive histology, presentation at our interdisciplinary tumor conference to consider adjuvant therapy options.