First, pharyngoscopy and laryngoscopy again, showing the fibrin-covered area where the tumor was resected. Tumor is visible in the direction of the hypopharynx. Confirmation of the indication. Initial PEG placement using the thread pull-through method. With very good diaphanoscopy, this is successful without any problems. Then skin disinfection of all relevant surgical areas and sterile draping. Then start with neck dissection on both sides: Neck dissection on the right (<CLINICIAN_NAME>): Skin incision and dissection through the subcutaneous fatty tissue. Separation of the platysma and subplatysmal dissection. Exposure of the anterior border of the MSCM and identification and preservation of the accessory nerve. Tracing of the omohyoid muscle and visualization of the. Gl. submandibularis. Visualization of the posterior venter of the digastric muscle. A large metastasis is seen in region Ib/II, which is located directly on the internal jugular vein. Dissection of the VJI and careful dissection of the metastasis. Ligation of a large branch of the VJI in order to be able to use it later for the venous anastomosis. Ligation of the V. Facialis for the same reason, exposure and preservation of the ACI, ACC and ACE as well as the vagus nerve and the cervical artery. Exposure and preservation of the hypoglossal nerve. Now successive removal of the lateral and medial neck preparation, i.e. from region Ib to V while preserving the plexus branches. Dissection of the superior thyroid artery and the facial artery in order to be able to use them later for the microvascular anastomosis Neck dissection on the left: Sharp dissection of the skin, subcutaneous tissue and platysma. Exposure of the anterior border of the sternocleidomastoid muscle, the digaster muscle, the accessorius nerve and the omohyoid muscle. Exposure of the cervical vascular sheath with the internal jugular vein and facial vein, ACC, ACI, ACE, vagus nerve, cervical plexus and subsequent removal of the neck preparation from level II to IV without complications and with preservation of all the structures mentioned. Insertion of a Redon drain. Two-layer wound closure, first of the platysma and then of the skin. Subsequent combined transcervical, transoral tumor resection: First dissection of the large neck vessels from the pharyngeal tube. Small outgoing vessels are ligated or treated. Snaring of the internal carotid artery, external carotid artery and common carotid artery as well as snaring of the hypoglossal nerve. V. facialis is placed cranially. The lingual artery is ligated and double ligated in the direction of the external carotid artery. Pharyngeal tube is dissected free towards the base of the skull. Border cord is preserved. Subsequent resection of the tumor with a safety margin of at least 1.5 to 2 cm on all sides, whereby the entire pharyngeal wall is resected in each case. The uvula with soft and hard palate on the right, the entire tonsil lobe, the mucosa at the transition to the base of the tongue, a lateral part of the base of the tongue to the medial side and the posterior palatal arch of the medial pharyngeal wall are resected. The resection is then completed from the outside, whereby both parts of the base of the tongue, the vallecula, upper parts of the arytenoid fold and the medial and anterior as well as small parts of the lateral piriform sinus wall must also be resected. The tumor is marked using sutures. In addition, marginal samples are taken from the lateral pharyngeal wall caudal to the right of the piriform sinus, from the lateral right arytenoid area and from the medial arytenoid area to the edge of the epiglottis. In the frozen section, all marginal samples were tumor-free as well as the specimen. In the cranial area, a resection is recommended again for safety reasons, therefore a strip several mm in size is taken from the soft palate to hard palate area up to the lateral alveolar ridge, here a thread-marked specimen is taken and sent for frozen section. There were no tumor infiltrates either in the mucosa or in the soft tissue, not even in the additional soft tissue removed. So now R0 resection. Defect size is measured at 12 to 13 x 8 to 9 cm. Marking on the forearm according to the required three-dimensional configuration. Subsequent removal of the radial artery flap <CLINICIAN_NAME>: skin incision and dissection through the subcutaneous fatty tissue. Locate and expose the cephalic vein and small venous anastomoses. Preparation of the pedicle between the brachioradialis muscle and the flexor carpi radialis muscle. Exposure of the venous star. Now successive further dissection of the pedicle and clipping of perforating vessels. Trimming of the 14x8cm graft. Ulnar subfascial dissection with identification and preservation of the ulnar artery and nerve. Now radial incision and radial dissection of the cephalic vein. Separation of several venous outlets by means of ligation. Separation of the cephalic vein distally. Locate the radial nerve R superficialis and preserve it. A small branch is pulled into the flap and removed. Careful further preparation of the remaining graft. After the R0 tumor has been resected, the graft is removed. Subsequent insertion of the radial flap into the defect and vascular suture: After the radial flap has been removed, rinse thoroughly with plenty of heparin. Insertion of the flap into the defect. Successive suturing of the flap with 3-0 Vicryl single-button sutures, partly with caudal and then cranial exposure. The flap fits very well into the defect and fulfills the three-dimensional requirement. The flap is then connected to the vessels. The superior thyroid artery is selected as the arterial vessel. After conditioning the vessels, suture with 9-0 Ethilon single-button sutures. Subsequent dissection of the V. thyroidea media and a branch of the V. facialis. The V. thyroidea media is anastomosed to the one outlet in the area of the V. cephalica using a 2.5 mm coupler after conditioning the vessels. Good venous return after opening the clips, positive smear phenomenon. The other outlet from the cephalic vein is then anastomosed with an outlet from the facial vein. Here too, after opening the clamps, the smear phenomenon is positive. Then clip all other available venous outlets. Careful hemostasis and irrigation. Wound closure in layers on both sides of the neck, on the right with insertion of a Redon drain, on the left with insertion of 2 flaps. Thorough inspection of the flap, which is vital. Removal of split skin + wound closure of the forearm: At the same time, large areas of split skin are removed from the right thigh in the usual manner. Application of sterile wound dressing in the area of the donor site. Two-layer wound closure in the area of the proximal forearm. Application of a wound dressing and a forearm splint. Completion of graft elevation without complications. Tracheostoma creation: A horizontal incision of about 4 cm 2 QF is made above the jugulum, sharply cutting through the skin, subcutaneous tissue and the platysma. The prelaryngeal musculature or infrahyoid musculature is exposed, entered in the midline and the thyroid gland is exposed. Dissection of the trachea between the cricoid cartilage and isthmus. The isthmus is cut and stitched on both sides. No major bleeding. Between the 2nd and 3rd tracheal cartilage clasp, the trachea is entered and a visor tracheotomy is created. The mucocutaneous anastomosis is created cranially and caudally. The patient is then intubated using an 8-gauge cannula. Completion of the procedure without complications. Then reintubation and insertion of an 8-gauge tracheostomy tube. The procedure is completed without complications. Patient goes to the intensive care unit for monitoring. Please leave heparin perfusor running at 1 ml/h for a further 5 days. Flap control via enoral inspection for 5 days according to schedule. Feeding via the inserted PEG tube for 10-12 days, then X-ray pre-swallow and, if necessary, diet build-up. However, swallowing training should always be planned due to the size and extent of the defect. Aspiration initially likely here. Overall cT3, more likely cT4 oropharyngeal carcinoma right cN2b. After receiving the final histology, please present at the interdisciplinary tumor conference.