Introductory consultation with the anesthesia department. Bronchoscopic intubation by the anesthesia colleagues. Positioning of the patient. Firstly, the PEG is inserted. For this purpose, insertion with the gastroscope under laryngoscopic control. Easy visualization of the stomach, whereby a partly exophytic, fleshy change can be seen in the area of the distal esophagus at the transition to the stomach entrance. Rather blurred boundaries. Multiple samples are therefore taken. The stomach is inconspicuous and clear on inspection, so that if diaphanoscopy is very good, the stomach is punctured without any problems and the PEG tube is then inserted using the usual thread pull-through method. Repositioning and inspection of the primary tumor region. An exulcerated tumor is seen in the area of the lateral floor of the mouth, extending into the anterior floor of the mouth to just below the midline, infiltrating the right-sided caruncle and directly approaching the alveolar ridge in the anterior and lateral floor of the mouth. Infiltration of the tooth pocket of the remaining canine. Infiltration of the edge of the tongue and extensive deep infiltration of the tissue towards the soft tissue and muscular floor of the mouth as well as towards the base of the tongue. The canine or lower incisor is therefore extracted first. Some of the teeth here are extensively decayed. Incision of the gingiva in the area of the alveolar ridge anteriorly and laterally, laterally of the lower jaw and subsequent removal of the entire mucosa with the periosteum from the bone. In the anterior and lateral areas, it can be seen that the tumor has consumed the periosteum and is located in the bone for a long distance. There are no clear signs of infiltration with erosion or destruction of the bone, so the decision is made to resect the tumor while preserving continuity. Resection of the lateral edge of the tongue with a sufficient safety margin up to the dorsal side and detachment of the floor of the mouth down to the depths with detachment of the musculature and detachment for later completion of the resection from the transcervical side. The entire exposed mucosal area is now covered with margin samples. These are shown to be completely free of tumor and dysplasia in the frozen section diagnosis. Repositioning of the patient for transcervical resection and neck dissection for cN2b neck status. After injection of Ultracaine with added adrenaline, the horizontal incision is made. Cut through skin and subcutaneous tissue. Dissection of the platysma. Dissection of the platysma. Exposure of the sternocleidomastoid muscle and preservation of the external jugular vein. Exposure of the omohyoid muscle. Release of the submandibular gland and exposure of the digastric muscle. Dissection of the cranial aspect of the sternocleidomastoid muscle shows that the mass is at least close to the muscle and appears slightly compressed. It was therefore decided to resect the cranial part of the muscle. Later, the posterior venter of the digastric muscle is also extirpated, as it is also cemented to the cervical conglomerate, which is largely localized in levels II and III. Free dissection of the internal jugular vein with exposure of the common carotid artery, vagus nerve, cervical plexus and cervical sinus. The aforementioned structures are microsurgically neurolyzed and relocated. Subsequent re-embedding of the aforementioned structures. Inclusion up to level V a. Anterior preservation of the superior thyroid artery. The facial vein must be removed in the event of infiltration, as must the accessorius and hypoglossal nerves. In addition, the facial artery and lingual artery must be removed, also in the case of infiltration. The internal jugular vein is clearly visible in the cranial part............................., but is not infiltrated and can be preserved in its continuity. Now dislocation of the submandibular gland. Level I b shows numerous and conspicuously enlarged lymph nodes. These are completely extirpated. Raising of the ramus marginalis mandibulae. Neurolysis and cranial displacement and re-embedding of the same. Resection sharply on the mandible and completion for resection enorally. In the case of pervasive growth in the area of the muscles of the floor of the mouth, removal of large areas of the affected muscles, macroscopically clearly in sano. It can be seen that a tumor formation is also growing submucosally into the right tonsil lobe. Therefore, the tonsillar lobe is included. Inclusion of the pharyngeal side wall on the affected side with extensive submucosal tumor growth and extirpation of the tumor, macroscopically especially in the soft tissue area in toto. The coverage is now completed with mucosal margin samples. These are again free of tumor and dysplasia in the frozen section. Marking of the specimen, especially the parts of the tumor close to the mandible and thus exposed. Final inspection of the mandible. Still no signs of destruction here. Therefore, the lower jaw is first significantly reduced over the entire exposed area using the rose bur. Grind down the tooth pockets of the extracted teeth close to the tumor. Then complete grinding with the diamond bur. Finally, vital and regular bone, so that an R0 situation can be assumed. After measuring the defect, the radialis graft is removed from the left forearm. Lifting of a graft measuring approx. 14x7 cm in total with mouth base and tongue edge configuration. Lifting of the graft in a bloodless state. First radial incision of the graft. Exposure of the brachioradialis muscle. Exposure and securing of the superficial ramus, radial nerve. Distal exposure of the radial vasa and removal. Ulnar preparation. Subfascial release of the graft. Cranial preparation and tracing of the pedicle. The cephalic vein is preserved and remains in situ. After ensuring the outlet of the ulnar artery, isolate the graft to the radial artery and two stronger draining veins in the area of the deep system. Reopening of the tourniquet. Regular hand perfusion. Good graft perfusion. Careful hemostasis in the area of the graft and in the area of the forearm and removal of the vital graft. After hemostasis, the wound is carefully closed in two layers in the area of the forearm and the full-thickness skin graft harvested from the right groin is implanted. A vacuum sealing pump was then applied and the Cramer splint was placed in the functional position. At the same time, the transplant was implanted. This is performed transorally and transcervically. Finally, exact fit and good reconstruction with preservation of tongue mobility. Tight conditions on all sides. Conditioning of the vascular pedicle. Preparation of the superior thyroid artery. Performing the arterial anastomosis with 8.0 Ethilon. This works well despite the difference in caliber. Immediate regular venous return. Conditioning of the venous stump of the facial vein. Measurement of a size 3.5 coupler. Problem-free performance of the venous anastomosis with the coupler system. Subsequent correct pedicle position. Positive spreading phenomenon and regular enoral graft perfusion so that, after careful wound inspection, a 10-gauge Redon drain is inserted and the wound is carefully closed in two layers. Finally, the tracheotomy is performed. A horizontal incision is made at the level of the cricoid cartilage. Cut through the skin and subcutaneous tissue. Expose the infrahyoid musculature. Entering the linea alba. This reveals a grayish, dark mass with soft tissue that cannot be further differentiated macroscopically. This does not initially appear to originate directly from the thyroid gland. Extirpation of the tissue on visualization of the cricoid cartilage. Another clear mass, but most likely in the sense of altered thyroid cysts or originating from the thyroid tissue. Resection as far as necessary for tracheotomy. The tissue is sent for definitive histology. Careful treatment of the thyroid gland, no dissection in the direction of the recurrent nerves. Insertion between the 2nd and 3rd tracheal ring. Creation of a wide visor tracheotomy and incision of the skin. Subsequent problem-free transfer to a size 9 low-cuff cannula, which is suture-fixed. The procedure is then completed. Final consultation with the anesthetist. Conclusion: Intraoperative R0-resected cT4a cN2b oral cavity carcinoma with extensive contact to the mandible. Intraoperative tissue biopsies in the distal esophagus and pretracheal region, most likely as dependent diagnoses. Please monitor the graft carefully postoperatively. Continue the intraoperative intravenous antibiotic treatment with Unacid 3 g for 24 hours. If the enoral graft heals properly, the first swallowing diagnostics can be carried out from the 8th postoperative day with initiation of the diet if necessary.