Detailed consultation with the anesthesia department regarding the intraoperative procedure before starting the procedure. Based on the above findings, a PEG was initially inserted. To do this, insert the flexible endoscope into the esophagus. Advance into the stomach. Inconspicuous conditions there. Good diaphanoscopy. Insertion of the PEG using the thread pull-through method in the usual way without complications. Removal of the endoscope. Now ablation of the neck region, the left forearm and the right groin. Due to the previous cardiac disease, there is no possibility of infiltration anesthesia with Suprarenin. Start of neck dissection on the right side: skin incision on the anterior edge of the sternocleidomastoid muscle. Incision of a platysmal flap. Dissection of the flap beyond the submandibular gland. Now expose the sternocleidomastoid muscle, the internal jugular vein, the common carotid artery and the vagus nerve caudally. Evacuation of the supraclavicular lymph nodes in front of and behind the vascular structures. The large metastasis that infiltrates the internal jugular vein can now be recognized. In addition, the sternocleidomastoid muscle is infiltrated. The muscle is therefore removed and the internal jugular vein is removed. Further dissection along the carotid artery to the bulb. Follow the external carotid artery with its branches. It can now be seen that these branches grow directly into the metastasis or are walled in by it. Therefore, the external carotid artery with its terminal branches is removed. The hypoglossal nerve, which runs completely through the tumor conglomerate, is also removed. Facial nerve monitoring was performed before the operation, as the metastasis also extended into the parotid region. Very difficult dissection in this area. Cutting through the tissue of the parotid gland. The facial nerve can be stimulated in depth. Exposure of the posterior digastric venter muscle. Dissection of the same. Beforehand, dissection of the internal carotid artery, which shows clear cranial kinking. It can now also be seen that the vagus nerve extends into the tumor. The vagus nerve must therefore also be removed caudal to the exit of the superior laryngeal nerve. The more cranial part remains intact. You are almost at the base of the skull. Further dissection through the parotid gland to the tip of the mastoid. Separate the muscle there. Exposure of the internal jugular vein in depth, which is completely thrombosed, and here the vein is again ligated and lanced. After resection of the accessorius nerve, it is finally possible to remove the entire tumor conglomerate with muscle vessels and nerves in toto. Now the patient is repositioned and the tonsil barring device is inserted: the tumor is cut around the tonsil lobe, passing over to the base of the tongue clinically in a healthy state. There is practically only a thin layer of connective tissue left. In principle, growth per continuitatem can be assumed. The musculature is extensively incised and circular marginal samples are taken and sent for frozen section. In addition, a marginal sample of the cranial vagus nerve is also taken. All marginal samples are found to be tumor-free. Now perform the neck dissection on the left side: skin incision on the anterior edge of the sternocleidomastoid muscle. Dissection in depth and exposure of the external jugular vein. Dissection of the internal jugular vein, the accessorius nerve, the posterior digastric venter muscle, the external and internal carotid artery. Dissection of the posterior part of the neck from cranial to caudal while sparing the above-mentioned structures. Then exposure of the hypoglossal nerve and dissection of the capsule of the submandibular gland. Dissection of the anterior part of the neck. The superior thyroid artery and the facial vein are identified as good connecting vessels. In the meantime, repositioning of the patient and resection of the submandibular gland on the right side with exposure of the lingual nerve and ligation of the excretory duct after it has been removed. Tracheotomy: Small Kocher collar incision, dissection through subcutaneous tissue up to the infrahyoid muscles. Spreading of these. Expose the thyroid isthmus. This is passed underneath, clamped off, cut through and supplied with puncture ligatures. Exposure of the trachea. Entering the 2nd/3rd intercartilaginous space. Creation of a broadly pedicled, visor-like Björk flap. Epithelialization of the tracheotoma in the typical manner with Ethibond sutures. Then insertion of a tracheal cannula with size 8 core, which is fixed with sutures. Now remove the radial flap on the right side. To do this, cut around the flap. Expose the underlying musculature. Expose the ulnar and radial arteries and the superficial nerve branch. Careful dissection in depth and lifting of the flap from distal to proximal. In the area of the elbow, follow the radial artery with the accompanying veins. The cephalic vein is also dissected. Overall, the accompanying veins of the radial artery are relatively thin, so that the cephalic vein is dissected into the elbow and deposited there. Exposure of the interosseous artery. This is left in place and finally the radial artery with the accompanying veins is removed. Removal of the complete radial artery graft. Wound closure in the upper part with subcutaneous and skin sutures. A full-thickness skin graft is then removed from the groin. This is cut around, removed and thinned out considerably. The wound is closed after mobilization of the skin with subcutaneous and skin sutures. A Redon drain is inserted at the same time. This full-thickness skin graft is now carefully sutured in the area of the removed radial flap and treated with a perforation. Then apply a wound dressing with Mepilex without VAC. Now reinsert the tonsil plug and suture in the radial flap. This is particularly difficult in the area of the base of the tongue. Many sutures must be placed here. It is now possible to suture the flap completely into the base of the tongue on the medial wall at the top in the area of the soft palate and completely laterally. Due to the radical neck dissection on the right, a vascular anastomosis is not possible here. For this reason, the vascular pedicle of the radial flap is placed on the left side via a tunnel after suturing. The skin monitor is sutured into the skin after incision of the skin for flap control. The vascular anastomosis of the radial artery with the superior thyroid artery is then performed. The vein is then connected to the facial vein using the coupler. Very good blood circulation. From the arterial side, no congestion in the venous system of the connecting vessel. Extensive hemostasis in the area of the right and left neck. Insertion of a Redon drain in each case. Irrigation. Subcutaneous suture, skin suture and wound dressing. At the end of the procedure, another detailed discussion with the anesthetist. The patient is intubated and ventilated and transferred to the intensive care unit. Further regular checks of the flap and vital functions are carried out there. Note: In addition to the operations listed above, a partial parotidectomy with facial monitoring was also performed.