First insert the McIVOR spatula. The tongue and the base of the tongue can be visualized well here, as can the tonsil region and the transition to the alveolar ridge. Cut around the tumor macroscopically with a safety margin of at least 1-1.5 cm on all sides. The tonsil is removed in its entirety. Resection extends over the lateral area of the glossotonsillar or glossoalveolar junction into the base of the tongue. A slightly deeper resection is performed in the base of the tongue if the main tumor is present. The base of the tongue is removed up to the vallecula and the border of the epiglottis or up to the beginning of the hypopharynx. The entire specimen is thread-marked. Due to the somewhat smaller macroscopic distances in the area of the vallecula, base of the tongue and epiglottis, a further marginal sample is taken here, which extends over the base of the tongue, the vallecula to the epiglottis and to the edge of the transition to the hypopharynx. The frozen section still shows in-situ infiltrates caudally at the transition to the hypopharynx and in the area of the caudal tongue base, vallecula and epiglottis. For this reason, another extensive resection is performed with the laser in the hypopharyngeal region: After the tumor has been adjusted, a large, at least 1-1.5 cm wide resected hypopharyngeal mucosa is removed with a 5 watt continuous wave superpulse. A marginal sample is then taken from the entire hypopharyngeal area up to the edge of the larynx or epiglottis. The entire mucosa of the lingual epiglottis up to the edge of the epiglottis is removed from the vallecula area up to the lateral border of the epiglottis. Another strip of mucosa is removed from the vallecula-epiglottis area as a marginal sample, whereby mucosa is now also removed from the front of the epiglottis. The mucosal resection again extends medially to the beginning of the hypopharyngeal inlet. Then, after insertion of the FK blocker, a superficial strip of the entire medially resected tongue base up to the vallecula is obtained as a post-resectate and then another strip as a marginal sample. All three marginal samples are sent in. No more tomorin infiltrates here, so now R0 resection. Overall relatively extensive tumor, but mostly growing superficially. Neck dissection can therefore be performed. Neck dissection is now performed on the right side: skin incision in typical manner. Exposure of the sternocleidomastoid muscle, omohyoid muscle and digastric muscle. Exposure of the cervical vascular sheath. Depiction of the internal jugular vein, internal/external carotid artery. Exposure of the vagus nerve, hypoglossal nerve and accessorius nerve. Removal of the lymph nodes from levels II to V, preserving the branches of the cervical plexus. Several conspicuous lymph nodes are visible, especially in level II. Dissection somewhat more difficult due to the previous operation in which a lymph node extirpation was performed. Neck dissection on the left side: Here, an arched skin incision starting from the mastoid at the anterior edge of the sternocleidomastoid and bending posteriorly. Exposure of the cervical fascia. Creation of a platysmal flap. Exposure of the anterior margin of the sternocleidomastoid. Dissection in depth. Exposure of the omohyoid muscle. Exposure of the submandibular gland. Now dissect in the direction of the digaster muscle. Trace the digaster muscle cranially. The facial vein is exposed here. Trace the facial vein caudally. Expose the internal jugular vein and the cervical vascular sheath. Now successively detach the anterior triangle, which goes to the final histology. Dissection up to the plexus branches. Now detachment of level II a, after exposure of the accessorius nerve. Break through the neck preparation under the nerve. Further dissection caudally. This exposes the hypoglossal nerve. Successive detachment of the neck preparation in levels II a and III and IV. The preparation is sent for final histology. Irrigation with Wassertoff and Ringer. No evidence of further bleeding. Insertion of a 10 redon. Platys suture. Skin suturing and completion of the neck dissection. A tracheotomy was also performed during the operation after it became clear that the operation would be more extensive. Repositioning for tracheotomy. Palpation of the cricoid cartilage. 3 cm long skin incision at the level of the cricoid cartilage. Cut through the subcutaneous tissue. Exposure of the prelaryngeal musculature. This is split in the middle. Exposure of the anterior surface of the thyroid gland. Tunneling of the thyroid gland on the trachea from the cricoid cartilage caudally. Bipolar coagulation of the thyroid gland and transection of the thyroid isthmus. Exposure of the trachea. Incision between the second and third cartilage clasps with the 15 mm scalpel. Widen the incision so that a sufficiently large tracheotomy is created. Now suture caudally and cranially. The lateral skin ends are closed with skin sutures. Insertion of an LE tube without complications. PEG insertion is necessary if the resection is extended. However, the patient underwent intestinal surgery with insertion of a Vicryl mesh alio loco. The scar extends into the upper abdomen. Mesh insertion was probably also palpated here. Therefore, despite the possibility of diaphanoscopy, a PEG was not inserted. This should be performed by colleagues in internal medicine or surgery. A transnasal feeding tube was inserted for nutrition. The procedure was completed without complications. The patient was admitted to the intensive care unit for postoperative monitoring. Overall extensive tumor, which had only grown superficially in situ. In any case, N2b status on the right. Please continue postoperative antibiotics for one week. Feeding via feeding tube or PEG for approx. 7-8 days, then, depending on swallowing function, cautious diet build-up. Discussion of further procedure in the interdisciplinary tumor conference.  