First pharyngoscopy and laryngoscopy: The tumor is found with ulceration in the area of the tonsil lobe, transition to the base of the tongue. Tumor is not very mobile and shows deep infiltration. As already recognizable in the pre-ultrasound or CT. Now sterile draping, injection of a total of 15 ml Ultracaine 1% with adrenaline into both sides of the neck. Start with transoral resection: Cut around the inside of the tumor with a safety margin of at least 1.5 cm to 2 cm on all sides. The tumor can be well dissected in the dorsal area up to the .................. musculature. Marginal samples are taken from the palatal arch, from the palatal arch extending laterally to the alveolar ridge, from the alveolar ridge extending to the middle of the tongue body, from the base of the tongue and from the posterior palatal arch area and the upper two thirds of the posterior wall of the hypopharynx. Tissue is also removed from the basal area directly above the tonsil lobe up to the per................. Musculature, which is sent in as cranial basal medial. All marginal samples are tumor-free in the frozen section. PEG insertion: advancement of the flexible esophagoscope into the stomach, where ............. diaphanoscopy is performed in a typical manner. Insertion of a 15 mm abdominal wall tube. Fixation to the abdominal wall. Sterile dressing. Now continue the tumor resection from the outside: skin incision as for neck dissection. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle. A large tumor conglomerate can be seen cranially. This infiltrates the sternocleidomastoid muscle, the internal jugular vein, the accessorius nerve and also grows into the external carotid artery. Cranial and caudal insertion of the sternocleidomastoid muscle. The internal jugular vein is also removed cranially and caudally and ligated twice. The cranial operation shows that the tumor can be easily dissected from the caudal edge of the parotid gland. Subsequently, touched tissue with suspected tumor infiltration is seen in the area of the digastric muscle. All muscles of the ............... fan are also resected, as is the submandibular gland. The hypoglossal nerve is clearly infiltrated by the tumor and is also resected. Further medial dissection shows that the tumor of the internal carotid artery can be dissected. The vagus nerve appears to be infiltrated. A marginal sample is taken, which shows clear tumor infiltrates. Resection of the vagus nerve and also the border cord, which is also involved in the tumor conglomerate. Separation of the carotid artery above the superior thyroid artery and suturing of this. Further branches of the lingual artery and facial artery and other smaller branches of the external carotid artery are included in the tumor preparation. Cranially, the external carotid artery is also ligated twice below the entrance to the parotid gland, as caudally. It can be seen that the tumor is growing from the pharyngeal wall towards the N3 metastases, as already visible in the imaging. Here the tumor is incised and dissected so that the neck preparation can be pushed off to the side. When the neck dissection is continued, level V a is massively interspersed with hardened lymph nodes, which indicate tumor infiltration. This means that almost all branches of the cervical plexus are resected as well as parts of the deep neck muscles. Resection extends caudally up to the venous angle. Level V b is also resected. The final result is an extended radical neck dissection. The part that grows per continuitatem in the direction of the tumor is marked with a suture. The tumor resection is then continued. All soft tissue structures are removed except for the internal carotid artery, including the parts of the masticatory muscles medial to the mandible. Resection extends basally to the prevertebral musculature. Middle area Adherence of the tumor to the musculature. This is partially resected as well. The resection also reveals massive retropharyngeal lymph nodes, which are thickened and appear to be infiltrated by the tumor. All lymph nodes are resected. The resection extends cranially to the entry of the carotid artery into the base of the skull. A cuff of 1 cm around the carotid artery remains suspicious for tumor. From all soft tissue in the area of the cranial ............... muscles and also from the suspicious cuff around the carotid artery. This is also sent to the frozen section as a cranial basal lateral sample. A marginal sample is also taken from the middle area, from the area of the prevertebral musculature, which is sent as medial basal. Continue the resection in the caudal direction. Here it extends to the piriform sinus entrance and includes parts of the arytenoid fold. A caudal basal margin sample is taken from the deep soft tissue. Mucosal margin samples are also taken from the piriform sinus and from the lower part of the hypopharynx up to the arytenoid region. All mucosal margin samples are healthy. The caudal basal margin sample is also healthy. Tumor infiltrate is visible in the medial basal margin specimen. Extensive resection of the prevertebral soft tissues is performed and another margin sample is taken. The cranial basal lateral margin specimen is not healthy, but broadly infiltrated by tumor. Extensive resection around the carotid artery is also performed here. However, the tissue quality does not change, so that tumor infiltration can be assumed here. Another marginal sample is taken. The marginal sample from the central area is negative, but there are still extensive tumor infiltrates from the marginal sample in the cuff around the internal carotid artery, which had now been visualized until shortly before entering the base of the skull. Laterally, .......... Due to the massive infiltration, which is also visible macroscopically, there is now an R2 situation at the base of the skull. Continuation is not possible without endangering the patient's life due to the massive infiltration. Therefore, wide coagulation of the tissue. Neck dissection is now performed on the right side: visualization of the sternocleidomastoid muscle. Exposure of the omohyoid and digastric muscles. Exposure of the cervical vascular sheath, common carotid artery, internal and external carotid artery, internal jugular vein and facial vein. Exposure of the superior thyroid artery and also the lingual and facial arteries. Careful attention is paid to the preservation of the arteries. Also visualization of the external jugular artery. Several .............. lymph nodes are now also removed during level II to V evacuation. The submandibular gland is also removed on this side in order to gain the facial artery for insertion of the flap. The accessory nerve and hypoglossal nerve can be exposed and preserved. Subsequently, tracheotomy in the typical manner and epithelialization of the cartilage to the neck skin after entering the 2nd/3rd intercartilaginous space. A small tracheostoma is created. Subsequently, the radialis flap is removed to cover the defect: the size of the defect is carefully measured in three dimensions and recorded on the forearm. Also recording a skin......... Successive lifting of the flap with skin........... First .............subfascial, then from radial. The radialis is ligated and treated using 4.0 Prolene sutures. All outgoing vessels are treated with ligatures or clips. The superficial and deep venous system is removed and exposed in the antecubital region, where it is exposed cranial to the cephalic vein and also a ............. of the radial vein. The radial artery is removed shortly before the exit of the interosseous artery. The stump is supplied with 4.0 Prolene. The veins are removed and the flap preparation is flushed with heparin. The veins are treated with ligatures. The procedure was performed under tourniquet. After opening the tourniquet, the flap reperfused well. Careful hemostasis in the area of the forearm skin. The cranial area is closed in layers. Defect is covered with split skin from the thigh. This was removed with a dermatome. Split skin with a thickness of 0.7 mm was obtained. This is successively incorporated into the defect, resulting in complete defect coverage. The thigh wound is treated with a hydrogel-Mepilex dressing. The forearm wound is treated with a Mepilex and hydrogel Lavanid dressing. Then wrap in absorbent cotton and apply a forearm splint using an elastic bandage. Repositioning of the arm splint. Due to the vascular situation on the left side, a tunnel is now created to the right side of the neck across the prelaryngeal muscles. This is three transverse fingers wide. The radialis flap is successively sutured into the defect using 3.0 Vicryl single-button sutures, whereby the overview is sometimes difficult. Tension-free suturing and complete coverage of the three-dimensional defect is achieved. The flap stalk is passed through the tunnel to the right side. Veins and arteries are conditioned here. The flap is sutured to the facial artery using 8.0 Ethilon single-button sutures. Good venous return after opening the clamps. The ..................................... veins are sutured between the cephalic vein and a branch of the facial vein using the 3.5 coupler system. After opening the clamps, good venous return............. ...... positive. The confluence of the radial artery is closed with clips. The stump of the outlet of the facial vein is also closed using clips and ligature. Subsequent irrigation of the entire wound area as well as shortly after completion of the tumor resection and careful hemostasis. Wound closure in layers on both sides of the neck with the insertion of a Redon drain. The skin monitor is sutured into place via a separate skin incision on the right paramedian side due to the course of the stalk in the anterior neck area. An 8-gauge cannula with a core is inserted and sutured in place. Once again the flap from transoral, good blood circulation. Completion of the procedure without complications. Patient goes to the intensive care unit for postoperative monitoring. Please continue antibiotics with Unacid for one week, as well as administration of heparin via perfusor 500 units per hour for 5 days. Flap control according to the scheme for 5 days. Feeding via the inserted PEG for 10 - 12 days. Then X-ray pre-swallow and, if necessary, diet build-up. Considerable dysphagia is to be expected with the extension of the resection, therefore early initiation of swallowing rehabilitation, including presentation to the voice and speech department.