After induction of anesthesia and intubation by the anesthesia colleagues, the first step is to determine the expansion again. Entry with the small bore tube under dental protection. The oral cavity is unremarkable on inspection and palpation. In the area of the oropharynx on the right, the exophytic mass can be seen starting at the caudal tonsil pole and extending caudally over the lateral pharyngeal wall. In the caudal extension, it extends to the entrance of the piriform sinus. However, the piriform sinus itself is free, as is the posterior pharyngeal wall. Growth across the pharyngoepiglottic fold towards the vallecula and the base of the tongue. The base of the tongue itself is not infiltrated in depth, here only superficial, circumscribed growth, but the right-sided vallecula and here extensions onto the lingual epiglottis. Overall, the T3 stage is already reached here due to the surface extension. A safe transoral resection is not possible due to the growth, the extension and the restricted mouth opening in the case of a mandibular fracture. The decision was therefore made to proceed primarily transverically. Repositioning of the patient. There is extensive lymph node metastasis on the right side, sonographically cN2b. Clinically, there is an extensive conglomerate, especially in level II and extending from here to level V a dorsally. Injection of xylocaine with the addition of adrenaline. Skin incision on the anterior edge of the sternocleidomastoid muscle extending nuchally. Cut through skin and subcutaneous tissue. Exposure and dissection of the platysma, which is not yet infiltrated. Exposure of the sternocleidomastoid muscle. Wide infiltration in the cranial part, therefore exposure of the omohyoid muscle. Release of the submandibular gland. Exposure of the digastric muscle, which is also not infiltrated. Separation of the sternocleidomastoid muscle caudally. Exposure and free preparation of the internal jugular vein, here a strong thyroid vein. On cranial dissection, however, the vein is clearly infiltrated, so that it is removed here. The facial vein is also removed. Exposure and preservation of the common carotid artery and vagus nerve. The hypoglossal nerve can also be preserved. Partial entrainment of the cervical plexus, otherwise en bloc development of level V a. Protection of the transverse cervical artery. Cranial detachment of the muscle from the sternocleidomastoid muscle. Supply of the internal jugular vein and en bloc removal of the neck preparation with the metastatic conglomerate. This is followed by partial release of the thyroid cartilage to release the right piriform sinus. Exposure of the common carotid artery. Exposure and isolation of the superior laryngeal nerve. Release of the pharyngeal side wall cranially into the tonsillar ligament with reduction of the digastric muscle. It is now apparent that the superior laryngeal nerve runs directly into the tumor conglomerate, so it is removed. Entering the pharynx below the expected tumor in the area of the piriform sinus. Free conditions here. Development of the tumor and successive resection and widening of the pharyngotomy. Removal of half of the epiglottis. Removal of a large cuff at the base of the tongue. Resection down to the pre-epiglottic fatty tissue. Cranial removal of the glossotonsillar groove as well as the entire tonsillar lobe up to the cranial side. Overall, a safety margin of at least 1 to 1.5 cm was maintained on all sides with a rather superficially growing tumor. Laterally, the entire musculature was removed to cover the basal part. Overall, however, the specimen was somewhat vulnerable, so that the explicit suture markings were made in all planes. Despite macroscopic in sano resection, the tumor was found to be margin-forming on all sides after embedding for the pathology colleagues, but the tissue was probably easy to tear. In the basal area, the mass was barely resected in sano, but without taking into account the overlying muscle tissue, so that a safe removal can be assumed here. After discussing the case with <CLINICIAN_NAME>, the tumor was again completely covered in situ with margin samples. All margins were found to be free of tumor and dysplasia, so that a histological R0 situation can now be assumed based on the findings. In the meantime, the neck was dissected on the left side and a tracheotomy was performed. Neck dissection on the left: Skin incision at the anterior border of the sternocleidomastoid muscle. Exposure of the sternocleidomastoid muscle and exposure of the omohyoid muscle. Release of the submandibular gland and visualization of the digastric muscle. Release of the anterior neck preparation while carefully protecting the facial vein, the superior thyroid artery and the cervical artery as well as the hypoglossal nerve. Free preparation of the internal jugular vein. Exposure and preservation of the accessorius nerve. Some enlarged nodes in level II, otherwise no suspicious changes. Clearing of the accessorius triangle and completion of level V with careful protection of the cervical plexus branches. Finally, inspect the wound and, if the wound is dry, insert a 10-gauge Redon drain and carefully close the wound in two layers. Now perform the tracheotomy: To do this, make a horizontal incision below the cricoid cartilage. Cut through the skin and subcutaneous tissue. Expose the infrahyoid musculature. Exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea. Exposure of the thyroid isthmus and transection. Insertion between the 2nd and 3rd tracheal ring. Creation of a broad-based Björk flap and insertion of the tracheostoma in the usual manner. At the end of the procedure, reintubation to a size 8 low-cuff cannula, which is suture-fixed. Due to the radical neck dissection of the right side and the defect configuration, the decision was made to lift a pedicled, supraclavicular island flap from the right. Measurement and marking of a graft measuring 6 x 11 cm in total, including the acromion. Trimming of the graft, strictly subfascial preparation. Dissection of the skin in the shoulder area. Lifting of a wide vascular pedicle and subsequent tension-free, but complex suturing of the vital flap. Subsequently tight conditions on all sides. Reconstruction of the tonsil lobe up to the posterior pharyngeal wall. Reconstruction of the entire pharyngeal side wall up to the piriform sinus as well as the base of the tongue and the transition to the supraglottic region. Subsequent careful wound inspection. Insertion of a total of 3 10 Redon drains and careful, two-layer wound closure. Subsequent completion of the procedure without any indication of complications. Conclusion: Intraoperative R0-resected cT3 cN2b oropharyngeal carcinoma on the right. Please perform a postoperative X-ray gruel swallow on the 8th postoperative day. Due to the extensive partial pharyngeal resection, a prolonged recovery of swallowing function can be expected. With final confirmation of the intraoperatively performed marginal samples, this is a safe R0 resection.  