Induction of anesthesia and intubation by the anesthesia colleagues. Then first sterile washing and draping of the neck area and performance of the tracheotomy by <CLINICIAN_NAME> and <CLINICIAN_NAME>, here skin incision below the cricoid cartilage, preparation of the prelaryngeal musculature, splitting of the musculature at the linea alba. Exposure of the thyroid isthmus, separation of the thyroid isthmus. Exposure of the anterior wall of the trachea. Insertion between the 2nd and 3rd tracheal cartilage. Creation of a visor tracheotomy. Then repositioning and remaining washing and draping. Neck dissection on the right, PEG placement and tracheostomy by <CLINICIAN_NAME>. Start of PEG insertion: insertion with the flexible oesophagogastroscope and easy pre-scanning with air insufflation into the stomach. Positive diaphanoscopy and problem-free placement of a PEG using the thread pull-through method without any problems. Dressing application. Transition to tracheotomy: positioning of the patient and marking of the incision and skin incision, subcutaneous preparation, pushing apart the infrahyoid muscles and exposing the thyroid isthmus. Undermining of the same, bipolar coagulation and separation of the isthmus from the trachea. Locate the space between the 2nd and 3rd tracheal cartilage and carefully enter. Creation of a visor tracheotomy. Transfer to a laryngectomy tube. Repositioning for tumor removal and neck dissection, primarily on the right side. Injection of 10 ml local anesthetic with adrenaline along the planned incision and along the right side of the neck. Skin incision, exposure of the sternocleidomastoid muscle, exposure of its profound surface, exposure and sparing of the accessorius nerve. Exposure of the posterior belly of the digastric muscle. Exposure and protection of the hypoglossal nerve. Exposure of the cervical vascular sheath. Visualization of the vagus nerve. Dissection of the lateral neck preparation, transection in the cranial area. Removal of the submandibular gland together with the attached lymph nodes. Dissection and gentle removal of the facial artery as a connecting vessel for subsequent flap preparation. Separation of the facial vein. Dissection inferiorly and exposure of the omohyoid muscle. Further dissection in a superior direction and lifting of the medial neck preparation. Hemostasis and leaving the site open for later flap preparation. Simultaneously, the tumor is released enorally by <CLINICIAN_NAME> and counter-operated on transcervically. This is followed by transoral, transcervical tumor resection: first insertion of the Mc Ivor blade and re-inspection of the tumor. The tumor is mainly located in the middle to lower part of the tonsillar lobe, passing just over the base of the tongue and growing slightly towards the glosso-alveolar groove or alveolar ridge, but at a clear distance. The tumor is now removed macroscopically with a safety margin of at least 1.5 to even 2 cm on all sides. The anterior palatal arch, the tonsil and parts of the posterior palatal arch are removed. During removal, the bone on the alveolar ridge is also exposed at the back by pushing away the periosteum here. Caudal resection of parts of the base of the tongue is carried out here at a clear distance. The beginning of the posterior wall of the hypopharynx and posterior wall of the oropharynx is also resected. Due to the growth at one point in depth in the direction of the submandibular gland, the tumor is then resected from the transcervical side as part of the neck dissection. After cutting the digastric muscle, the submandibular gland is mobilized. The hypoglossal nerve is exposed and spared for this purpose. The lingual nerve was already severed during the resection from the enoral side, as it runs too close to the tumor or was infiltrated by the tumor. Glandula submandibularis is now pushed into the oral cavity en bloc with the tumor and attached soft tissue. It can be seen that the tumor was resected macroscopically with a wide safety margin on all sides. Nevertheless, another marginal sample was taken at the alveolar ridge extending to the glossotonsillar groove. Tumor is marked with a thread and sent for frozen section together with the marginal sample. The frozen section shows carcinoma in situ on all sides, partly with transition to microcarcinoma, only in the area of the posterior palatal arch there is no carcinoma in situ. A large strip of mucosa is now removed from the alveolar ridge, whereby the mucosa is removed down to the alveoli. In addition, a large resectate is removed from the caudal pharyngeal wall, as well as a wide resectate from the pharyngeal entrance, vallecula area to the base of the tongue. All resected specimens are sent for re-examination as frozen sections, with the sutures placed away from the tumor. Carcinoma in situ again in almost all specimens. After consultation with the pathologists, this appears to be a field carcinoma. Therefore, only the specimen in the caudal pharyngeal region appears to be free of tumor and no carcinoma in situ is detectable. This is followed by a final marginal sample from the vallecula/base of tongue area, where the sutures are again placed away from the tumor. However, this is no longer a frozen section examination but a final examination. It is no longer possible to take a mucosal sample from the alveolar ridge, as the resection has already reached the beginning of the alveolus. The mucosa is healthy towards the floor of the mouth. R1 affected areas are therefore the dorsal alveolar ridge and the base of the tongue/valley area. Overall tendency towards field carcinomatization after consultation with the pathologist. Neck dissection on the left side (<CLINICIAN_NAME>): Injection of 10 ml ultracaine solution, making a skin incision from the mastoid at the anterior margin of the sternocleidomastoid caudally with a slight swing laterally. Expose the platysma. Create a platysma flap anteriorly, expose the sternocleidomastoid. Mobilization of the muscle, sharp dissection in depth up to the plexus branches. The cranial accessorius nerve is exposed. Now follow and mobilize the omohyoid muscle and expose the substructure of the submandibular gland. The gland is now pulled upwards until the digaster muscle is exposed. Exposure of the digaster muscle. Now insert a retractor in the caudal region. Expose the internal jugular vein. Dissect the vein from caudal to cranial, follow the outlets anteriorly, coagulate a small outlet. Now mobilize the neck preparation in level II in the anterior triangle, exposing the hypoglossal nerve and the facial artery. There is bleeding from a small branch of the facial artery, which is ligated. Separation of the anterior triangle up to the omohyoid muscle. Now evacuate level IIa. Pass the neck preparation under the accessorius and dissect caudally via levels III and IV, sparing the plexus branches of the vagus nerve and the internal carotid artery, which is exposed. Finally, check for bloodlessness, which is present. Insertion of a Redon drainage and two-layer wound closure. At the same time, the radial artery graft is lifted from the arm. The extent of the visible tumor was measured to be 8 x 6 cm. A buffer with a final graft size of 12 x 8 cm is also lifted from the forearm. For this purpose, the graft is marked, the graft is cut around and the skin is incised in the proximal forearm area. Exposure of the vein star. The second concomitant vein of the flap stalk has no contact with the superficial system or the venous confluence. The first concomitant vein opens into the venous confluence. Then lift the radialis graft, exposing the brachioradialis muscle of the superficial ramus of the radial nerve, the radial artery and lift the graft from the tendon bed and dissect the pedicle in the usual manner. Deposition of the graft in the usual manner and closure of the forearm with split skin from the thigh. The frozen section still showed carcinoma in situ with microinvasion in the marginal samples, therefore <CLINICIAN_NAME> resected 3 more times and the 2nd resection also showed carcinoma in situ with microinvasion, the third resection was taken in the area of the vallecula and sent for final histology. In the end, the resection significantly enlarged the defect so that the graft could only be sutured in under tension and with difficulty. The anastomosis was then performed using the facial artery. The facial artery is altered like a plaque and the endothelium has already detached over a long distance within the vessel. Therefore, 2 suture attempts were necessary to connect the radial artery with the facial artery. Two veins were couplers, one directly from the concomitant vein with an outlet from the internal jugular vein and then two outlets from the venous confluence with two outlets from the facial vein. At the end, insertion of a Redon drainage (Jackson type) and two-layer wound closure and insertion of an 8-gauge tracheostomy tube. Inspection of the oral cavity and the graft. The graft shows a good blood supply (random sample). Prior to the tumor resection, a PEG was inserted using the thread pull-through method without any problems.