First, pharyngoscopy and laryngoscopy again: The exophytic tumor is seen in the area of the lingual epiglottis, vallecula and base of the tongue, extending from the paramedian left to the right, with deep ulceration in the direction of the hyoid bone. There is also a second tumor in the area of the pharyngeal wall on the right at a distance of 1-2 cm. Aryepiglottic fold free on both sides. In the CT, the tumor extends to the hyoid bone. Therefore, laser resection does not make sense, so the primary indication is a transcervical procedure with flap coverage. This is followed by PEG placement: insertion of the flexible esophagoscope into the stomach. Once the diaphanoscopy has been performed, a 15 mm stomach wall tube is inserted without complications. This is also fixed to the abdominal wall in the typical manner. Subsequent repositioning for tumor resection, neck dissection on both sides and flap coverage. Injection of a total of 15 ml Ultracaine with adrenaline into the sides of the neck for the planned apron incision. Sterile draping of all relevant surgical areas. First, creation of an apron incision and lifting of the skin in the sense of an apron flap subplatysmal in a typical manner up to the level above the hyoid bone and at the level of the submandibular gland on both sides. First neck dissection on the right: visualization of the sternocleidomastoid muscle, omohyoid muscle and digastric muscle. Exposure of the internal jugular vein and facial vein. Exposure of the external jugular vein. V. facialis is set off cranially at the gland. This is connected to the relatively narrow internal jugular vein by a dense venous plexus. Exposure of the vagus nerve, hypoglossal nerve and accessorius nerve. Subsequent evacuation of neck level II-V with visualization and preservation of the branches of the cervical plexus. Several enlarged and suspicious lymph nodes, particularly cranially. Subsequent neck dissection on the left by <CLINICIAN_NAME>: Drawing of the skin incision in the sense of an apron flap. Skin incision, transection of the cutaneous and subcutaneous tissue and the platysma. Creation of a platysmal flap by subplatysmal dissection of the flap cranially. This is done until the submandibular glandulae are exposed. First turn to the left side. Exposure of the anterior border of the sternocleidomastoid muscle and dissection along the muscle in depth until the branches of the cervical plexus are exposed. Identification of the omohyoid muscle and dissection on the muscle up to the hyoid bone. Identification of the submandibular gland and opening of the glandular capsule as well as release of the gland and dissection anteriorly up to the hyoid bone. Identification of the digasatric muscle. Identification of the N. accessorius and sparing of the free preparation of the nerve. Division of the neck dissection on the internal jugular vein with the blunt dissecting scissors. Now carefully detach the lateral neck preparation Level II, III and IV as well as V in one piece. This is carried out with constant bipolar coagulation of minor bleeding and protection of the surrounding nerve structures. Identification of the hypoglossal nerve and now also release of the medial part of levels II and III. Tracheostoma creation (dictation <CLINICIAN_NAME> is still missing) Then combined transoral, transcervical tumor resection: once again visualization and securing of the following structures with the vessel loop N. hypoglossus, A. carotis interna and externa and A. lingualis. Exposure and preservation of the superior laryngeal nerve. Exposure of the pharyngeal wall and separation of this from the area of the vascular sheath and the spinal column. The digastric and stylohyoid muscles are each cut for a better overview. The submandibular gland is removed. Exposure and preservation of the lingual nerve. The Mc Ivor blade is then inserted. The 2nd tumor is exposed transorally and the pharyngeal tube is opened above it under internal and external control. Successive development of the tumor. The entire hyoid bone with attached residual parts of the infrahyoid and suprahyoid musculature is removed. Removal of the supraglottic region including the epiglottis up to the upper edge of the thyroid cartilage with the uppermost parts of the aryepiglottic fold. The lower part of the base of the tongue is resected almost to the opposite side. The lingual nerve from the opposite side is not touched. Vallecula with attached pre-epiglottic fatty tissue and hyoid bone is completely resected. Resection extends cranially to the lower tonsil pole in the area of the pharyngeal wall on the right. Subsequent suture marking of the specimen. Removal of a marginal sample from the base of the tongue. Preparation as a whole in healthy tissue, including marginal sample from the base of the tongue. In the area of the pharyngeal wall in the area of the second tumor, there is still moderate dysplasia up to the edge. Mucosa is therefore removed again in the area mentioned in a width of approx. 5 mm. This is sent for final assessment. This is followed by careful hemostasis and irrigation. Lifting of the radialis graft by <CLINICIAN_NAME>: Marking of the graft to be lifted in the presence of <CLINICIAN_NAME>. S-shaped skin incision on the proximal forearm and visualization of the venous confluence in the crook of the elbow. A strongly developed cephalic vein can be seen which can be followed distally to the radial edge of the flap. Skin incision in the area of the radial edge of the flap and dissection down to the forearm fascia. This exposes the external ramus of the radial nerve, which can be safely spared. Now also ulnar skin incision and dissection down to the deep forearm fascia. Subfascial dissection, leaving the peritendineum intact and folding the flap over to the border of the extensor carpi radialis muscle. Identification of the flap pedicle and trial clamping using a vascular clamp for 5 minutes: during this time, a good perfusion signal should be measured pulsoxymetrically. Then clamp the distal radial artery with the accompanying veins and place two vascular ligatures using a prolene thread. Successive dissection of the flap pedicle from the depth with constant supply of the perforator vessels using a vessel clip and bipolar coagulation. Dissection of the flap pedicle up to the antecubital fossa, identification of the venous vessels and the outlet of the radial artery. Separation of the radial artery and placement of a vascular ligature. The veins are now also removed and the radial artery graft is lifted without complications. The wound is closed using split skin from the right thigh by <CLINICIAN_NAME> and <CLINICIAN_NAME>. Then removal of split skin from the right thigh in a typical manner. Closure of the forearm wound and insertion of the split skin into the skin defect. Application of Mepilex dressing and swab dressing, which is molded with absorbent cotton. Arm is fixed in Cramer splint with elastic bandage in functional position. Attachment of the arm. Radialis flap, which was rinsed with heparin after removal, is now inserted into the defect. Successive suturing of the radialis flap into the defect. This is achieved completely tension-free with complete coverage of all relevant defect areas. Radialis is fixed anteriorly to the thyroid cartilage and cranially on the right to the lower tonsil pole. Due to the remaining lack of volume, a Remmert flap is lifted on both sides in the typical manner on the superior thyroid artery and supplied with the cervical artery. Mobilization is carried out to such an extent that the flap can be inserted as a volume substitute without any problems, onto the radial artery flap. Vascular anastomosis beforehand: conditioning of the right lingual artery and the radial artery. Suturing with 9-0 Ethilon single-button sutures. After opening the clamp, good arterial flow, good venous return. Subsequent conditioning of both cephalic veins and the confluent vein. The confluent vein is anastomosed with an outlet from the vascular network of the facial vein, which is connected to both the external and internal jugular vein, using a 2.5 mm coupler after appropriate vascular conditioning. Good venous return after opening the clamps. Positive smear phenomenon. One of the cephalic veins is anastomosed with another outlet from the facial vein using a 2.5 mm coupler. Here too, after opening the clamps, venous flow is good, smear phenomenon positive. All other outlets are clipped both in the area of the flap pedicle and in the area of the facial vein. Subsequent careful irrigation. Hemostasis. Now insertion of the Remmert flap pedicled on both sides into the volume defect. Fixation using several Vicryl sutures both on the mandible and on the upper edge of the thyroid cartilage. Inspection of the flap enoal, which shows good blood circulation. Extensive irrigation again. Hemostasis. Layered wound closure now with epithelialization of the tracheostoma and insertion of a Redondra ring on the left and insertion of 3 flaps on the right. Insertion of a size 8 tracheostomy tube and suture fixation. Completion of the procedure without complications. Patient admitted to the intensive care unit for postoperative monitoring. Please continue antibiotics, which were started intraoperatively, with Unacid for one week. Nutrition via the inserted PEG for 10 days, then gruel swallowing and start with swallowing training if prolonged dysphagia is expected. Flap control for 5 days in a typical manner using Doppler sonography or clinically. Continue heparin perfusor 500 E/h for 5 days. Total cT4 vallecula/base of tongue carcinoma with secondary carcinoma in the area of the right pharyngeal side wall. V.a. cN2c status. Please present postoperatively at the interdisciplinary tumor conference to plan further adjuvant therapy.