First, after preparation and intubation by the anesthesia colleagues, inspection of the primary tumor region by palpation and with the small bore tube. The largely submucosal, tumorous mass can be seen in the area of the posterior pharyngeal wall, directly adjacent to the retropharyngeal metastasis, which is now clearly progressive compared to CT imaging. Cranially, exophytic, exulcerated tumor part, palpatory just not reaching the tubal bulges. The tumor grows caudally to the border of the oropharynx and hypopharynx and takes up the entire width of the posterior wall of the oropharynx up to the lateral wall. Plastic tracheotomy is now performed for better exposure due to the extensive tumor. To do this, enter at the level of the cricoid cartilage. Cut through the skin and subcutaneous tissue. Exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea. Dissection of the thyroid isthmus and, after exposure, insertion between the 1st and 2nd tracheal clasps. Performing a visor tracheotomy. Incision in the usual manner and problem-free reintubation, initially on an 8 mm Woodbridge tube, later on an 8 mm low cuff cannula, which is suture-fixed. First turn to the transoral procedure. Perform a left paramedian soft palate split. Good exposure of the nasopharyngeal part of the tumor for this. This ends well in front of the choanae and does not reach the tubal bulges on either side. Cut around the entire tumor. Perform a lateral tonsillectomy on both sides. Isolation of the tumor to the prevertebral fascia. Here the tumor is only moderately displaceable and has a large surface area. Due to the exposure, transition to the transcervical approach. For this purpose, a skin incision is made on the left side at the anterior edge of the sternocleidomastoid muscle with a slightly left paramedian tumor. Cut through skin and subcutaneous tissue. Exposure of the sternocleidomastoid muscle while preserving the auricular nerve. Exposure of the omohyoid muscle, submandibular gland and digastric muscle. Removal of the anterior neck preparation with careful preservation of the superior thyroid artery and the cervical artery. The facial vein is initially preserved, but is later removed during the transcervical procedure, as is the extremely strong occipital artery. Exposure of the accessorius nerve. Free dissection of the internal jugular vein and clearing of level V while carefully preserving the cervical plexus branches. Subsequent resection of the digastric muscle, already directly connected to the enoral side. Widening of the pharyngotomy. Now exposure in depth. The tumor can be resected by removing the pharyngeal musculature. The prevertebral fascia only needs to be detached in a circumscribed manner. In this case, the resection distance is narrow, but macroscopically and palpatorily completely in sano, and there is also no evidence of perforation of the prevertebral fascia. Removal of the tumor now via transcervical. During mobilization, the nasopharnygeal portion is ruptured. For this reason, the tumor is sent in 2 parts ........ and a complete in-sano resection is also macroscopically present in the marginal area. The tumor is now completely imaged with marginal samples. All tumor........., tumor- and dysplasia-free, so that an R0 situation can be assumed. For the exposure of the tumor, the external and internal carotid arteries had to be visualized in a long-distance view. Extensive pharyngotomy. Therefore absolute indication for defect coverage using a free graft. Neck dissection of the right side should be performed first. In principle, the same procedure is used here. Expose the limiting musculature. Removal of the anterior neck preparation and preservation of the cervical artery, the superior thyroid artery and the facial vein. Free preparation of the internal jugular vein. Exposure of the accessorius nerve. Clearing of the accessorius triangle and level V with careful protection of the nerves. No evidence of lymphatic leakage and dry wound conditions. Finally, exploration and cranial dissection of the external and internal carotid artery, in case of metastatic contact with the internal carotid artery on CT. This is completely explored. No further metastasis or tumor parts, so that the metastasis is also resected in toto. The defect is now measured. Decision to lift an anterolateral thigh graft from the right thigh. For this purpose, after doppler sonographic identification of 3 skin perforators, marking of a graft measuring 11 x 6 cm in total. Medial incision. Cut through skin and subcutaneous tissue. Cutting through the fascia lata. Exposing and securing the rectus femoris muscle. Strictly subfascial dissection. Exposure of the pedicle vessel. Performing the extension incision. Complete resection of the graft. A musculocutaneous perforator course is visible, therefore a narrow muscle cuff is included. Isolation on the vascular pedicle and placement of the vital graft in the area of the pedicle vessels. Careful hemostasis and, if the wound is dry, insertion of a 10-gauge Redon drain and careful, multi-layer wound closure. Subsequently, combined transoral and transcervical insertion of the graft. Here, the suturing conditions were considerably more difficult and laborious. Finally, however, intact and tight conditions on all sides both cervically on both sides and nasopharyngeally. Suturing of the temporary soft palate cleft. Subsequent left-sided cervical pedicle positioning. First conditioning of the occipital artery. This shows extensive vascular damage to the intima. Further conditioning of the facial artery. Damage here too, but better conditions. Several suture attempts with 8-0 Ethilon are initially frustrating here, however, with rapid cessation of venous return flow. Subsequent conditioning of the submental artery. After suturing the artery, a sufficient circulation with proper flap vitality is now achieved, so that in vital conditions, after positioning the pedicle on both sides, the wound is irrigated and, in dry wound conditions, a 10 Redon drain is inserted and the wound is carefully closed. Conclusion: Intraoperative R0-resected, extensive cT3 cN1 to 2a oropharyngeal carcinoma of the posterior pharyngeal wall with extension into the nasopharynx and hypopharynx. Extensive retropharyngeal metastasis adjacent to the tumor. The patient received intraoperative intravenous antibiotics with Sobelin 600 mg, which should be continued for 24 hours postoperatively. If the graft heals properly, a gradual increase in diet is possible from the 8th postoperative day. However, due to the extensive resection, a protracted recovery of the swallowing function is to be expected.