After induction of anesthesia and intubation by the anesthesia colleagues, an inspection of the primary tumor region is performed: Here, the primary tumor is submucosal in the area of the right tonsil lobe, circumscribed and extending into the soft palate, with moderate displacement towards the soft tissues of the neck. The submucosal tumor growth ends in the caudal area of the tonsil. Right cervical subcutaneously grown and clearly inflamed lymph node metastasis with subsequent puncture and open site. Due to the extent of the metastasis, PEG insertion was initially carried out: For this purpose, insertion with the gastroscope under laryngoscopic control. Easy to advance into the stomach. With good diaphanoscopy, easy puncture of the stomach and insertion of the PEG tube using the usual thread pull-through method. Subsequent transoral tumor resection: This is performed as an extended radical tumor tonsillectomy. Complete removal of the anterior floor of the mouth. Resection up to the alveolar ridge. Circumscribed here, with removal of the alveolar ridge mucosa, resection and removal of the posterior palatal arch. The muscles of the posterior palatal arch are also resected extensively if they are adherent. A muscle cuff can also be left on the tumor laterally. However, the tumor extends into the soft tissues of the neck. Overall, complete tumor removal transorally. The specimen also shows an in sano resection, so that the specimen is thread-marked for frozen section diagnostics. All mucosal margins as well as the basal margins are free of tumor and dysplasia, so that an R0 situation can be assumed here. Turning to the neck dissection of the right side: Here, the perforated skin area is cut around in a spindle shape. Release of the skin. Subcutaneous, extensive inflammatory surrounding of the metastasis is also seen later, so that the skin resection must be extended here, with no clear distinction between tumor and inflammatory events. Widen the skin incision caudally. Exposure of the sternocleidomastoid muscle cranially on the mastoid and caudally. Widespread infiltration of the muscle. It is therefore cut at its insertion and origins. Visualization of the omohyoid muscle. Clearly inflammatory scarring in the direction of the submandibular gland. However, this is not infiltrated. Release of the capsule. Exposure of the digastric muscle. This is also resected if adherent to the metastasis. Infiltration and consumption of the accessorius nerve. This is not exposed. The internal jugular vein, vagus nerve and common carotid artery are visualized caudally. At the level of the metastatic conglomerate, the vein is infiltrated and thrombosed cranially. For this reason, the vein is removed caudally. Preservation of the common carotid artery and the hypoglossal nerve. Separation of the occipital and facial arteries. Partial resection of the cervical plexus. No further metastasis in the direction of level Vb. Overall, however, complete resection of the right cervical draining veins due to the extent of the tumor. Resection of the metastatic conglomerate and the attached neck preparation in toto. After removal, there is now a defect measuring approx. 3 cm to the primary tumor region. Therefore, blunt opening is performed here with a clear indication for defect reconstruction due to the pharyngocutaneous fistula. Due to the resected superficial and deep veins on the right side, there is no possibility of a microvascular connection here. Therefore, the indication is for defect coverage using a pedicled supraclavicular island flap. If there is good skin mobility here, the defect is measured. An area measuring 8x5 cm is then incised in a spindle shape. Resection down to the muscle fascia. Removal of the muscle fascia. Release of the tissue at the acromion and isolation of the supplying vascular area from the transversa colli artery, which could already be identified by Doppler sonography before lifting the flap. Release on all sides of the trapezius muscle at the clavicle, so that a well mobile pedicle can be developed overall, with completely tension-free insertion into the oral cavity. Prior to this, the skin incision was widened and the skin dissected. Insertion of the flap into the oral cavity and successive suturing. Subsequently, tight conditions on all sides with a vital flap and overall sufficient reconstruction. The wound is then irrigated on the right cervical side. If the wound is dry, insertion of two 10-gauge Redon drains. Careful two-layer wound closure. Neck dissection of the left side was performed at the same time as defect reconstruction: skin incision on the anterior edge of the sternocleidomastoid muscle. Exposure of the sternocleidomastoid muscle, omohyoid muscle, submandibular gland and digastric muscle. Clearing of levels II to Va and preservation of the facial vein, superior thyroid artery, accessorius nerve, hypoglossal nerve and cervical plexus branches. Exposure and preservation of the vagus nerve and common carotid artery. Overall, no macroscopically highly visible nodes. Subsequent wound irrigation and inspection. If the wound is dry, insertion of a 10-gauge Redon drain. Careful two-layer wound closure. Due to the extent of the procedure, a final protective tracheotomy is performed: incision at the level of the cricoid cartilage. Skin incision. Cut through skin and subcutaneous tissue. Exposure of the cricoid cartilage and the anterior surface of the trachea, after separation of the infrahyoid muscles. Exposure and transection of the thyroid isthmus. Entering the trachea. Widening by performing a visor tracheostomy and then successive incision of the tracheostoma. Subsequent easy transfer to a size 8 low-cuff cannula, which is suture-fixed. Subsequent enoral inspection and, if the graft was vital, completion of the procedure without any indication of complications. The patient received intraoperative intravenous antibiotics with Unacid 3 g. Please continue this for 24 hours postoperatively. Conclusion: Intraoperative R0-resected cT2 cN2b-cN3 oropharyngeal carcinoma on the right. Please feed via the PEG tube for 7 days. Subsequently, with regular enoral healing and flap perfusion, gradual diet build-up. This should be functionally possible. Subsequently, prompt recanalization should be possible.  