First of all, the PEG was inserted. Entry with the gastroscope under laryngoscopic control, easy visualization up to the stomach, which is inconspicuous and free. There is median scarring from the arteriocoronary bypasses performed and a scar in the lower abdomen, no other known gastric or intestinal interventions. Therefore, with excellent diaphanoscopy, problem-free puncture of the stomach and placement of the PEG using the usual suture pull-through method. Subsequent positioning of the patient, where an extensive contracture in the neck muscles as well as the shoulder-arm muscles is noticeable. Therefore, limited conditions here. First perform the tumor resection. Insertion of the tonsil plug. There is an exophytic mass of the soft palate relatively median. The uvula is completely consumed by the tumor. The mass measures a good 3 x 2 cm in the area of the soft palate and extends to the posterior palatal arch on both sides, no further deep infiltration on palpation. The extent is just cT2. Good differentiation from the surrounding mucosa. Resection is now carried out at a distance of approx. 1.5 cm in the area of the soft palate; in the transition to the posterior palatal arch, resection is carried out taking the tonsils with it. Dissection of the tonsils using the dissection technique on the right side with questionable infiltration of the upper tonsil pole, otherwise the tonsils are free with a regular capsule. Partial resection of the posterior palatal arch on both sides, vertical transection of the soft palate and removal of the tumor en bloc with subtotal soft palate resection and both tonsils with palatal arches. It can be seen that the tumor also spreads almost symmetrically to the posterior wall of the soft palate. Here too, a safety margin of approx. 1 cm can be maintained. The resectate is completely thread-marked for frozen section diagnostics and is assessed here as an R0 resected caricinoma. After meticulous hemostasis, a defect of both tonsillar lobes is seen, slightly larger on the right side. A subtotal soft palate defect was found. Therefore confirmation of the indication for defect coverage using a radialis graft. A graft measuring 10 x 5 cm and tailored to the soft palate reconstruction is measured. The neck dissection is now performed first. Start with the left side. As described above, the extensive contracture in the area of the sternocleidomastoid muscle can be seen. First, a curved skin incision on the anterior edge of the sternocleidomastoid muscle, very short neck overall. Cut through the skin and subcutaneous tissue. Exposure and transection of the platysma. Exposure and preservation of the external jugular vein and the auricularis magnus nerve. Exposure of the sternocleidomastoid muscle. Extensive contracture. Now explore the sternal part, here clearly contracted, tendinous tissue, partial severing of the attachment, but clear loosening. Exposure of the omohyoid muscle, exposure of the submandibular gland and the digastric muscle, removal of the anterior neck preparation with careful protection of the superior thyroid artery, the cervical artery and the hypoglossal nerve. Preservation and visualization of the V. facialis and free preparation of the V. jugularis interna. Identification and visualization of the accessorius nerve, evacuation of the accessorius triangle with careful protection of the nerve and evacuation of level 5 with careful protection of the cervical plexus branches. Palpation of level 1b. Final wound inspection and, if the wound is dry, wound irrigation with Ringer's solution and careful two-layer wound closure after insertion of a 10-gauge Redon drain. Overall, there was no clinical evidence of metastasis. Turning to the opposite side. In principle exactly the same procedure here. Cut through the skin and subcutaneous tissue. Exposure and transection of the platysma. Exposure and preservation of the external jugular vein and the auricular nerve. Exposure and dissection of the sternocleidomastoid muscle. Also in the case of extensive contracture. Release of the sternal insertion. Exposure of the omohyoid muscle, exposure of the submandibular gland and the digastric muscle. Release of the anterior neck preparation with careful protection of the superior thyroid artery, the facial vein, the hypoglossal nerve and the cervical sinus. A clear venous plexus with communication of the external jugular vein and two strong facial vein branches can be seen on this side in the area of the veins. ...... in the connection between the external jugular and facial veins. Otherwise preservation of the venous structures. Now free preparation of the internal jugular vein. Exposure of the accessorius nerve. Free dissection of the vein, evacuation of the accessorius triangle with careful protection of the nerve, evacuation of level 5 with careful protection of the cervical plexus branches. Evacuation of level 1b, no suspicious conditions here. The digastric muscle is now resected. Exposure of the carotid artery, exposure of the bulb and the external and internal splitting. Along the carotid artery towards the tonsillar ligament, here blunt opening of the tonsillar ligament. Combined transoral and transcervical widening of the access up to a width of 2 QF. Finally, good conditions. Minutious hemostasis, careful protection of the hypoglossal nerve, which is located at the lower edge of the pharyngotomy. Now turn to the graft elevation. The preoperative examination revealed a moderate vascular situation in the area of the forearm, negative elliptical test, but unclear Doppler sonographic conditions, therefore the graft was lifted without blood emptying. Radial marking of the graft. First incise the radial artery, cut through the skin and subcutaneous tissue. Expose the cephalic vein. This is not lifted if the superficial venous network is irregular. Perform the Haydn maneuver. Expose and protect the superficial radial nerve ramus. This is very weak here, the pulse is barely palpable. After isolating the vascular pedicle, the vascular pedicle is now clamped with the bulldog clamp. No changes in the area of the blood supply to the hand. Further dissection. Exposure of the brachioradilaris muscle. Exposure of the flexor carpi ulnaris. Strictly subfascial preparation. The proximal radial artery is now explored again. Here, a larger caliber, complete cutting of the graft and isolation on the vascular pedicle. The blood supply to the graft is normal, so the distal vascular pedicle is ligated while the blood supply to the hand is also excellent and unchanged. Subfascial release of the graft, isolation on the vascular pedicle. Clipping and ligation of distal vein branches. There is a strong connection of the accompanying veins to the superficial venous system. Capping to the deep venous system. Isolation of the radial artery after visualization of the ulnar artery. It can be seen that there is little pulsation in the area of the vascular pedicle. Good pulsation proximally. After initially slight vascular spasm, which is completely resolved by applying heat, the graft is removed with normal vitality. Meticulous hemostasis and, if the wound in the forearm area is dry, careful two-layer wound closure and insertion of the full-thickness skin graft from the groin. Finally, application of a vacuum sealant dressing and application of the stretcher splint in the functional site. To lift the full-thickness skin graft from the groin, measure the required skin defect and trim the skin. Strictly cutaneous preparation, subcutaneous mobilization. Meticulous hemostasis. Insertion of a 10-gauge Redon drain and careful, strong two-layer wound closure under good tensioning conditions. The graft is now inserted from transcervical to transoral. The soft palate is reconstructed with a good fit, good reconstruction of the tonsillar lobes and cervical pedicle positioning with tight conditions on all sides and sufficient soft palate reconstruction. Conditioning of the vessels. 2 strong superficial veins were lifted in the area of the radialis graft. Conditioning of the artery. The superior thyroid artery is now prepared if the positional relationship is good. If the arterial pressure conditions are good, clip the distal vascular pedicle. Shorten the superior thyroid artery until a tolerable caliber equivalence is achieved. Slight caliber advantage in the area of the radial artery. Now carefully suture the vessel and adapt the caliber with 8 .................... and Ethilon. This works well. After reopening the Acland clamps, immediate tightness and good venous return with regular flap vitality. One flap vein is now clearly leading in the area of venous return. Therefore clipping of the 2nd vein. Conditioning of the deep facial venous branch. Measurement of a coupler size 3.5. Easy guidance of the venous anastomosis with the coupler. Subsequent good venous reperfusion and reopening of the artery. Regular flap vitality with intact and stable conditions and good pedicle positioning. After final wound inspection under dry conditions, a 10-gauge Redon drain is inserted caudally. This is separated from the anastomosis with a muscle adaptation suture and finally careful two-layer wound closure with multiple inspections of the regular graft. In the meantime, a plastic tracheostomy was performed. For this, a skin incision was made approximately at the level of the cricoid cartilage with the larynx very low. The cricoid cartilage can at best be palpated through the skin. Cut through the skin and subcutaneous tissue. Exposure of the ethmoidal musculature. Dissection of the musculature. Exposure of the cricoid cartilage. Extremely difficult dissection conditions here with deep cricoid cartilage. Exposure of the cricoid cartilage. Exposure of the strong thyroid isthmus. Dissection of the thyroid isthmus after puncture ligation in the sense of a tobacco pouch suture. Exposure of the anterior surface of the trachea. Here too, the conditions are much more difficult. Insertion between the 1st and 2nd tracheal ring. Attempt to create a Björk flap. Clearly porous cartilage conditions in the area of the trachea. Laborious insertion of the tracheostoma with repeatedly difficult adaptation conditions. Finally, stable tracheostoma and, at the end of the operation, problem-free reintubation to an 8 mm low cuff cannula. Suturing of the cannula and, on final inspection, regular flap vitality and completion of the procedure at this point without any indication of complications. Conclusion: Intraoperative R0 resected cT2 cN0 G2 uvular carcinoma. Tracheotomy was already performed preoperatively on pulmonological recommendation for the best possible weaning prerequisite in case of possible problems with severe COPD. Meticulous flap monitoring postoperatively. After regular weaning, the gradual build-up of the diet can begin on the 8th postoperative day if the enoral conditions are intact. If swallowing function is normal, prompt decannulation depending on the pulmonary situation.