CT shows a vallecula carcinoma with extensive infiltration of the base of the tongue and clearly endophytic growth. The decision was therefore made to proceed primarily with transcervical tumor resection. Therefore, in the case of left-sided tumor growth, first turn to neck dissection on the right side: For this purpose, submandibular skin incision with the option of extending a Gluck Sörensen incision. Exposure and transection of the platysma. Creation of a platysma flap. Exposure of the sternocleidomastoid muscle, exposure of the omohyoid muscle. This shows a very pronounced anterior jugular vein. This is dissected and preserved. Dissection of the omohyoid muscle up to the hyoid. Exposure of the submandibular gland, exposure of the digastric muscle. Complete and expose the digastric muscle up to the hyoid. Exposure and preservation of the facial vein. Expose the entire length of the digastric muscle. Now continue dissection of the anterior neck preparation. Expose the cervical artery. Expose the superior thyroid artery. Free preparation to maximum length. Preservation of the cervical artery. Exposure of the hypoglossal nerve. Now expose the accessorius nerve. Free dissection of the internal jugular vein. Level Va now shows several nodes up to about 1 1/2 cm. Careful clearing of the accessorius triangle with careful protection of the nerve. Trace the cervical sinus retrograde via the internal jugular vein and dissect level Va, carefully protecting the cervical plexus. Now remove the digastric muscle. Expose the hyoid horn - release and separate with scissors to widen the access. Now enter latero-cranially of the hyoid horn and perform the pharyngotomy. Widen the pharyngotomy. The extent of the tumor can now be easily palpated. Large parts of the tumor are submucosal. The tumor infiltrates at least 2/3 of the base of the tongue, extends on the left side to the pharyngeal wall, is exulcerated in the area of the vallecula, which is completely consumed. The vallecula is infiltrated and perforated from lingual to laryngeal. Now successive dissection of the tumor, including at least 2/3 of the base of the tongue. Inclusion of the pre-epiglottic fat, which is inconspicuous. Complete release of the epiglottis up to the petiolus. Resection of the left-sided tumor up to the pharyngeal side wall. The tumor ends at the glossotonsillar groove. Cranial macroscopic removal in sano. The specimen is now sent to frozen section diagnostics with the entire specimen thread-marked and is all found to be R0. Only in the area of the base of the tongue on the left is there a maximum basal distance of 0.1 cm. A resection and a final marginal sample are performed here. Now turn to the neck dissection on the opposite side: Here, too, a submandibular skin incision is made. Exposure and transection of the platysma. Creation of a platysma flap. Level II shows a pronounced conglomerate of metastases which, after exposure of the sternocleidomastoid muscle, clearly infiltrates the muscle and also reaches close to the mandible. Now first expose the borders. Exposure of the sternocleidomastoid muscle, exposure of the omohyoid muscle up to the hyoid. A pronounced anterior jugular vein is also well preserved here. Removal of the anterior preparation, the superior thyroid artery can be preserved. Further dissection clearly shows that the lymph node conglomerate in the area of the venous angle clearly infiltrates the internal jugular vein. Therefore, expose the internal jugular vein caudally. Separation of the internal jugular vein and the sternocleidomastoid muscle. Cranial en bloc dissection including level Va. Careful protection of the carotid artery and the vagus nerve. Cranially, the lingual artery and occipital artery must be removed in the area of the external carotid artery after ligation. Involvement of the hypoglossal nerve and accessorius nerve. Cranially, the mass extends close to the mandibular branch. Branches from the oral branch clearly extend into the tumor and are deposited. Here the conglomerate does not reach the submandibular gland. This is skeletonized and left in place. The defect to the pharynx is now visible at the level of the resected hypoglossal nerve. Removal of the internal jugular vein cranially. Parallel to this, elevation of an antero-lateral thigh flap - at the patient's request from the left. A defect measuring a good 7 x 6 cm had already been previously ............. Determination of the perforator line and doppler sonographic identification of 2 equally strong perforators in the midline area. Marking of the graft. Medial skin incision. Separation of the subcutaneous tissue and identification of the rectus femoris muscle. Strictly subfascial dissection. Expansion of the muscle fascia and exposure of the vascular pedicle. Blunt dissection to expose the vascular pedicle in its course. It can now be seen that one perforator runs purely fasciocutaneous, a second one myocutaneous. Performing the relief incision and further dissection and visualization of the vascular pedicle. This is relatively narrow with a clear resection of the base of the tongue. Now subtotal entrainment of the vastus lateralis, entrainment of the muscle while carefully preserving the perforator plane. This is successful with good perforator visibility and in the slim patient. Now dissect the vascular pedicle. Very small caliber vessels can now be seen. Laborious dissection and tracing of the vessels. Exposure of the outlets towards the rectus femoris and transverse outlets towards the vastus lateralis. Slight increase in the caliber of the artery so that it can later be deposited shortly before the outflow of the vessels mentioned. Further dissection of the accompanying veins. Very laborious dissection and hardly any increase in caliber. Several potential veins are now removed and elevated. Prior to this, regular flap control and, if blood flow is good, removal of the graft. Finally, if the site is free of bleeding, insertion of a 10 Redon drain and careful two-layer wound closure after removal of excess skin. Now suture the graft with the aid of sutures. The pharyngeal wall on the left and the entire base of the tongue and the resected supraglottic structures are now reconstructed as a patchplasty. Partially laborious suturing with deliberately sparing pharyngotomy and clearly pronounced muscle cuff. Finally, good graft fit. Microscopic dissection of the vessels. It shows the superior thyroid artery after free preparation in the appropriate caliber size for the flap artery. Due to the position of the planned arterial anastomosis, the decision was made to anastomize the vein with the facial vein. Free preparation of the facial vein with maximum length gain. Performing the arterial anastomosis with 8.0 Ethilon. This works well. Placement of a final suture after reopening the Acland clamp. Regular flow with tight conditions and immediate regular venous return. One venous vessel now has a clear advantage in terms of reflux. Tilt the remaining veins and, after removing the facial vein and exposing the vessel, pass the anastomosis with a size 2.5 coupler. After reopening the Acland clamps, regular flow with immediately good venous return. Padding of the anastomosis with a piece of fat and careful, two-layer wound closure with insertion of a flap. Doppler sonographic identification of the flap pedicle and suture marking. Parallel to this, with dry wound conditions, closure of the left side of the neck after insertion of a 10 Redon drainage with two-layer wound closure. Performing a plastic tracheotomy: Horizontal skin incision for this. Cut through the subcutaneous tissue and expose the infrahyoid musculature. Dissecting the musculature, exposing the thyroid isthmus. Bipolar coagulation of the less pronounced isthmus. Exposure of the anterior surface of the trachea and the cricoid cartilage. Insertion between the 2nd and 3rd tracheal clasp. Creation of a broad-based, pedicled Björk flap and insertion of the mucocutaneous anastomosis. Subsequent problem-free transfer to an 8-gauge cannula with inner core and completion of the procedure at this point. Conclusion: cT4a cN2b-cN2c left vallecular carcinoma with subtotal tongue base resection and epiglottis resection. Intraoperative macroscopic and microscopic R0. Due to the extensive resection of the base of the tongue and the epiglottis resection, the prognosis and swallowing function should be viewed with caution. Prolonged swallowing rehabilitation in any case. If possible, the cannula should be left in place for at least 5 days postoperatively. Regular Doppler sonography and endoscopic checks as usual.