After an introductory consultation with the anesthesia colleagues, preparation by the anesthesia colleagues and positioning of the patient. The primary tumor is inspected first. This is done with the small bore tube under dental protection. There is a rough mass in the right tonsil lobe extending submucosally into the soft palate. On palpation, it clearly extends laterally towards the soft tissue of the neck and clearly exceeds the caudal border of the tonsillar lobe. Growth into the glosso tonsillar groove, but no tongue infiltration. The tumor extends submucosally to the mandible, but clearly does not infiltrate it. The PEG is now inserted. This is done with the gastroscope under laryngoscopic control. Easy advancement into the stomach. Excellent diaphanoscopy, problem-free puncture of the stomach and insertion of the PEG tube using the usual thread pull-through method. Inconspicuous oesophagus on reflection. After positioning the patient, injection of xylocaine with adrenaline additive cervically due to lateral growth, primarily transcervical procedure to secure the cervical vascular sheath. For this purpose, a skin incision is made at the anterior edge of the sternocleidomastoid muscle, the skin and subcutaneous tissue are cut, the platysma is cut, the sternocleidomastoid muscle, the omohyoid muscle, the submandibular gland and the digastric muscle are exposed. First expose and clear the anterior neck preparation and preserve the superior thyroid artery, the hyperglossal nerve and the cervical vein. A true facial vein is not pronounced, preservation of the extremely strong external jugular vein. Now free preparation of the internal jugular vein. Macroscopically, there are clearly conspicuous nodules in levels II and III due to their size. Anterior neurolysis of the hypergossic nerve with attached cervical vein. Reintegration of the nerve, followed by exposure of the accessorius nerve, also here neurolysis and reinsertion of the nerve. After complete exposure of the cervical vascular sheath, the vagus nerve is also exposed. This is also mobilized by neurolysis and then re-embedded. Elongated exposure of the common carotid artery, the bulb and the internal and external carotid artery. The facial vein is alloyed during subsequent dissection of the transcervical access artery, but is otherwise preserved. All carotid branches. The accessorius triangle is then dissected and level V dissected, carefully preserving the cervical plexus branches. The submandibular gladula is now released with careful protection and release of the marginal mandibular ramus, re-embedding of the nerve, separation of the gland, resection of the digastric muscle, posterior venter, removal of level I b. Here too, several nodules measuring up to 1.5 cm. The tumor can now be clearly palpated in the area of the lateral pharyngeal wall. Now combined transoral and transcervical procedure. Cut around the tumor with a visual distance of a good 1 cm. Reaching from paraovular over the soft palate up to the algular ridge and just including the lateral edge of the tongue, also resection up to the posterior floor of the mouth. It can be seen that the tumor also clearly infiltrates the posterior palatal arch including the musculature. Therefore complete involvement of the muscular posterior palatal arch. Resection down to the posterior pharyngeal wall. Macroscopic in sano resection on all sides both to the edges and clearly basally. Transcervical completion of the tumor dissection also towards the caudal pharyngeal wall. Macroscopic in sano. The tumor specimen is now sent in thread-marked for frozen section diagnostics. This shows discontinuous tumor growth in the area of the lateral margin. Therefore, according to the buccal mucosa of the alveolar ridge and the posterior floor of the mouth, resection specimens are taken and imaged with new margin samples. These are finally diagnosed as tumor-free in the frozen section diagnostics. Otherwise, all resection margins are tumor-free without high-grade dysplasia. The defect is now measured for subsequent reconstruction. First the neck dissection of the opposite side. To do this, make a skin incision on the anterior edge of the sternocleidomastoid muscle, cut through the skin and subcutaneous tissue, cut through the platysma, expose the sternocleidomastoid muscle and the omohyoid muscle, Release of the submandibular gland, exposure of the digastric muscle, removal of the anterior neck preparation while preserving the superior thyroid artery and then neurolysis of the hyperglossal nerve with attached cervical nerve. Re-embedding of the nerve. Dissection of the internal jugular vein, exposure of the accessorius nerve, neurolysis of the nerve and re-embedding. Clearing of the accessorius triangle with careful protection of the nerve. Subsequent evacuation of level V a with careful protection of the cervical plexus branches. There may be a caudal indication of lymph leakage. Overall, no suspicious lymph node changes on the left side. Final wound irrigation with Ringer's solution, insertion of a 10-gauge redon drain if the wound is absolutely dry and careful two-layer wound closure. The plastic tracheostomy is then performed. Skin incision below the cricoid cartilage. Cut through the skin and subcutaneous tissue, expose and cut through the infrahyoid musculature. Exposure of the cricoid cartilage and the anterior surface of the trachea. Exposure of the thyroid isthmus. Dissection of the thyroid isthmus after supply. Insertion between the second and third tracheal ring. Creation of a wide-base styled PJ flap and subsequent insertion of the tracheostoma with mucocutaneous anastomosis. Subsequently, problem-free reintubation to a size 8 low-coff cannula. The radialis graft is then lifted from the left forearm. After marking, the 9x6 cm graft is measured with a special soft palate and mouth configuration. Cutting around the graft, exposing and taking along the cephalic vein. Exposure of the superficial ramus, radial nerve and complete preservation of the nerve. Exposure of the brachioradialis muscle. Exposure of the distal vascular pedicle, transection of the vascular pedicle. Reciprocal exposure of the flexor carpi ulnaris muscle, strictly subfacial release of the graft. Subsequent preparation of the pedicle, including the cephalic vein. Cubital part showing a strong vascular connection from superficial to deep venous systems. Therefore preservation of the venous bridge. Exposure and preservation of the common interosseous artery. Removal of the radial artery. After reopening the tourniquet with a vital graft and regular blood supply to the hand. Careful hemostasis. Subsequent careful two-layer wound closure. Incision of the full-thickness skin graft harvested from the right groin. Application of a vacuum dressing and positioning of the ......... in a functional position. Subsequent repositioning of the arm. For full-thickness skin harvesting from the right groin. Incision of an oval skin area measuring approx. 10x6 cm. Strictly cutaneous elevation. Careful subcutaneous mobilization, insertion of a 10-redon drain in dry wound conditions and multi-layer wound closure. Now combined transoral and transcervical graft fitting. Overall very good fit and sufficient and complete reconstruction of the defect. Conditioning of the superior thyroid artery and the strong superior thyroid vein. For anastomization, perform the arterial anastomosis with 8.0 Ethilon. This is successful with immediate venous return. Conditioning of the vein. Measure a size 4.0 cuppler and perform the venous anastomosis with the cuppler system. Subsequent regular graft perfusion as well as positive spreading phenomenon and regular style pulsation, so that after careful wound irrigation and inspection, insertion of a 10-gauge Redon drainage and careful wound closure. The patient was then repositioned, a final consultation was held with the anesthesia colleagues and the procedure was completed with a vital graft. The patient received intraoperative intravenous antibiotics with 3g Unacid. Please continue this for 24 hours postoperatively. Conclusion: Intraoperative R0-resistant at least cT2 and cN2B oropharyngeal carcinoma on the right. Careful postoperative flap monitoring. If the graft heals properly and the graft is intact, a gradual diet can be started from the eighth postoperative day with a good prognosis with regard to swallowing function. Presentation at our interdisciplinary tumor conference to plan adjuvant therapy.