Introductory consultation with the anesthesia department. Induction of anesthesia and intubation by the anesthesia colleagues. First of all, insertion with the small water tube and adjustment of the tumor region. The tumor is extremely difficult to position with the small water tube, making laser resection impossible. In addition, the tumor covers large parts of the right base of the tongue and extends laterally to the metastasis coming from the neck, so that laser resection is not recommended for this reason either. In addition, this would result in a very large defect that would be worth covering anyway. Entering with the flexible gastroesophagoscope and pre-scanning into the stomach. Insertion of a PEG using the thread pull-through method. This is successful with good diaphanoscopy. Application of a wound dressing. Start with neck dissection on the right side. The tumor is marked transorally beforehand. Large lymph node conglomerates with infiltration of the sternocleidomastoid muscle can be seen. The sternocleidomastoid muscle is therefore initially removed caudally. Lymph node conglomerates can be dissected from the omohyoid muscle. Dissection of the larynx. First expose the medial digastric muscle or the hypoglossal nerve. Laborious dissection of the lymph nodes from the structures that can initially be preserved. Then dissection of the tendon of the digastric muscle. Then dissection from the dorsal side. Co-resection of the lower parotid pole and removal of the sternocleidomastoid muscle cranially. Exposure of the cervical vascular sheath from the caudal side. Exposure of the internal jugular vein, common carotid artery, later the internal and external carotid artery. The internal jugular vein is infiltrated from the middle and is initially set off caudally and ligated twice. Further dissection cranially along the carotid artery. The internal and external carotid arteries can be dissected, but parts of the branches of the external carotid artery are infiltrated. The superior thyroid artery and lingual artery can be preserved. The facial and superficial temporal arteries must also be removed in the other small branches. The hypoglossal nerve is now massively infiltrated, the nerve is distended. Macroscopically clear infiltration. Separation of the nerve. Further dissection along the internal carotid artery. Here the tumor can be laboriously dissected from the internal carotid artery, as well as from the vagus nerve. Inclusion of the stylohyoid muscle. Cranial separation of the internal jugular vein. However, this is hardened from the wall near the base of the skull, here a marginal sample. Subsequently, further removal of the lymph nodes between the branches of the cervical plexus from level V a and b. Multiple lymph nodes are positive here. Branches of the cervical plexus can be partially preserved, the cranial accessorius nerve must also be severed and removed. Finally, the massive lymph node conglomerate and multiple affected lymph nodes can be removed. Level II to V removal. Soft tissue is removed cranially from the area of the internal carotid artery up to the bifurcation. This soft tissue is carcinoma-positive, as is the marginal sample of the internal jugular vein, which was removed close to the base of the skull. Thus an overall R1 to R2 situation. No further measures due to the involvement of vital structures. Snaring of the superior thyroid artery, the lingual artery and the internal carotid artery. Exposure of the pharyngeal wall. Tumor resection: Exposure of the upper edge of the tumor from the inside. Dissection through the pharyngeal wall under control from the inside and outside. Exposure of the tumor and successive removal of the tumor with a safety margin of 1 to 1.5 cm on all sides, also macroscopically towards the depth. Parts of the pharyngeal wall from the tonsillar lobe and parts of the glossoalveolar junction are removed. Parts of the vallecula are removed caudally, the base of the tongue is largely removed in the caudal and middle section, with the resection extending to just above or partly above the midline. The tumor is removed in its entirety and marked with sutures. As a hardened nodule was noticed cranially when the tumor was removed, which may also have corresponded to the tonsil, a marginal sample is taken from the pharyngeal wall area with remaining parts of the tonsil. In the frozen section, this tumor margin specimen as well as the specimen in the healthy state, relatively scarce in the basal region due to tissue shrinkage, but to be classified as R0 during resection. Neck dissection on the left side. For this purpose, an apron flap is created in the usual manner. Exposure of the anterior border of the sternocleidomastoid muscle. Exposure of the submandibular gland. Exposure of the digastric and omohyoid muscles. Exposure of the cervical vascular sheath. Exposure of the internal jugular vein. Exposure of the facial vein. Exposure of the superior thyroid artery. Exposure of the accessory nerve and hypoglossal nerve. Displacement and, at the end of the operation, re-embedding of the accessory nerve and hypoglossal nerve in the sense of a neurolysis. Clearing of the neck levels II a to V a while sparing the plexus branches. Several rough, spherical lymph node metastases are clearly visible here, all of which are also removed. After the neck dissection on the left, the tracheotomy is performed. The incision is made at the lower edge of the cricoid cartilage. Dissection down to the thyroid isthmus, which is cut through. Thorough bipolar coagulation. Opening of the trachea between the 2nd and 3rd tracheal cartilage. Creation of a mucocutaneous anastomosis and reintubation. Elevation of the radial forearm flap on the left: Palpatory identification of the distal radial artery. Marking of the flap boundaries (size) on the distal forearm, proximal to the flexor retinaculum, with an S-shaped incision running proximally into the cubital fossa. Incision of cutaneous and subcutaneous tissue starting proximally. Identification and visualization of the venous confluence in the cubital fossa. Identification of the cephalic vein and dissection of the vein distally with integration into the radial graft margin. Identification of the ramus externus of the radial nerve and elevation of the radial portion, leaving the peritendineum of the tendons of the brachioradialis muscle intact. Subsequent ulnar incision down to the forearm fascia. Incision of the fascia and subsequent subfascial elevation of the ulnar edge of the graft up to the tendon of the flexor carpi radialis muscle. Care is taken to leave the peritendineum on the flexor tendons and to spare the ulnar artery. Identification of the distal radial artery and trial clamping with a vascular clamp. After 5 minutes with good oxygen saturation measured by pulse oximetry (measured on the index finger), the vessels are removed with subsequent ligation (Prolene 6.0). Successive detachment of the flap pedicle from the pronator quadratus and flexor pollicis longus muscles with ligation of the outgoing perforators using a vascular clip into the cubital fossa. Exposure and protection of the radial nerve on the medial side of the brachioradialis muscle. Exposure of the brachial artery, V. mediana cubiti, A. ulnaris. First removal of the radial artery, then of two veins of the superficial venous system. Vascular ligation by means of a bypass ligature (artery) and vascular clip (veins). Subtle hemostasis in the area of the wound bed using bipolar coagulation forceps. Two-layer wound closure in the area of the proximal forearm. Deposition of the radialis graft and preparation of the vascular situation in the elbow. Lifting of split skin on the right thigh. Application of Starsil wound powder and application of a foam dressing. Preparation of the wound bed on the left forearm. For this purpose, the superficial ramus of the radial nerve is embedded laterally into the tissue so that it cannot come into contact with the split skin and is protected. Partial adaptation and reduction of the wound area and suturing of muscles to tendons that are particularly exposed. Fitting of the split-thickness skin graft and suturing of the split-thickness skin graft in the usual manner. At the end, the application of ball swabs to areas where the split skin had no contact with the subsurface. Application and suturing of compresses and application of a dorsal forearm splint. Insertion of the graft, initially transorally. Here the defect extends up to the soft palate and into the tonsillar lumen. The tonsil is also removed. The remaining graft must be sutured in from the transcervical side. Due to the ultimately even larger defect than planned, the pharynx must be partially gathered. However, this is not a problem, so that the graft fits well in the end. The stalk is transferred to the left side; there is no longer a connecting vessel on the right side due to the radical neck dissection. The superior thyroid artery is used on the left side. This is particularly difficult as all other vessels in the neck are very small in caliber, but the radial artery is very large. Therefore, the caliber jump must be specially bridged using suture techniques. The venous anastomosis is performed on the facial vein and the external jugular vein. The flap pedicle has very good pulsation at the end and the flap is well supplied with blood. Insertion of two Redon drains. Application of a pressure dressing on both sides. The patient goes to the intensive care unit intubated and ventilated through the tracheostoma with a size 8.0 tracheostomy tube. Final consultation with the anesthesia department. Please continue postoperative antibiotics for at least 24 hours. Flap checks according to the usual schedule.