After induction of anesthesia and complicated bronchoscopic intubation, at the request of the anesthetist, start with the tracheotomy, as the patient is very, very difficult to ventilate. For this, injection of Ultracaine and skin incision in the usual manner. Dissection down to the muscles. Push the muscles in the linea alba to the side. Exposure of the thyroid gland. Exposure of the thyroid isthmus. Coagulation of the thyroid isthmus. Visualization of the trachea. Entering the trachea between the 2nd and 3rd tracheal cartilage. Creation of a mucocutaneous anastomosis in the caudal region and transfer to a laryngectomy tube. Then repositioning for PEG placement. To do this, the flexible esophagoscope is used and the tube is advanced into the stomach. It can be seen that the esophagus and stomach are unremarkable. Then, with good diaphanoscopy, a PEG is inserted using the thread pull-through method. This is successful without any problems. Then enter with the small bore tube and inspect the hypopharynx and larynx. The hypopharyngeal area is unremarkable. The tumor begins at the base of the tongue in the middle, it consumes the entire epiglottis and extends to the aryepiglottic fold on both sides. Pocket fold and vocal fold level as well as piriform sinus on both sides are not affected by the tumor. Then sterile washing and covering and creation of an apron flap in the usual manner. Start dissection on the left side. Expose the anterior margin of the sternocleidomastoid, then expose and dissect the internal jugular vein. Detachment of the cervical vascular sheath from the larynx. Exposure of the hyoid bone. Then transfer to the right side. Here too, detachment of the cervical vascular sheath from the larynx and pharyngeal region. Exposure of the hyoid bone. Then detachment of the suprahyoid musculature from the hyoid bone and careful approach to the pharynx from the left side. Then small pharyngotomy from the left side. Aspiration and inspection of the tumor including palpation. Complete the pharyngotomy just above the hyoid bone at the base of the tongue on the opposite side. Then skeletonize the larynx on both sides. Release the piriform sinus on both sides using a freer. This can be done easily without tearing the mucosa. Now carefully cut around the tumor with a safety margin of 1 ˝ cm. Protect the piriform sinus. Dissection along the postcricoid area. Then lowering of the larynx below the cricoid cartilage. Removal of a large resectate in the entire tongue base area from left to right, as the resection was relatively close here macroscopically, followed by removal of marginal samples: Base of tongue, pharyngeal side wall on both sides and piriform sinus as well as the postcricoid region. The entire marginal samples are thread-marked for frozen section and are diagnosed as R0. Now transition to neck dissection, initially on the right side by Stegmann. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid remnant. Exposure of the internal jugular vein. Free preparation of the internal jugular vein. Exposure of the facial vein. Exposure of the nervus accessorius and the nervus hypoglossus. Release of the neck preparation at all levels while protecting the plexus branches. Transition to neck dissection on the left side. For this, also expose the sternocleidomastoid muscle. Exposure of the accessorius nerve, the hypoglossal nerve and the lingual artery. Exposure of the cervical vascular sheath and removal of the neck preparation, sparing the plexus branches. The entire dissection is extremely difficult in this patient as she is very corpulent and not very mobile in the neck. Performing the esophageal myotomy. This involves entering the esophagus. The esophagus is found to be relatively narrow, so the decision is made to perform a posterolateral myotomy on the left side. The esophageal muscles are carefully incised so that only the mucosa remains. Then transition to the Provox system. Enter with the appropriate trocar and pull through the Provox, then roll out the edges in the usual manner. Then start with the pharyngeal suture, initially in the caudal area. Placement of a marking suture and adaptation of the mucosa using a submucosal single-button suture technique. Then stretch open the base of the tongue and perform the pharyngeal suture at the right and left corners. Then complete the pharyngeal suture again from caudal to cranial. Unfortunately, the mucosa tears in the cranial area on the left side, as the entire pharyngeal wall is very thin here. Careful re-stitching must be carried out here, reopening some of the sutures that have already been placed, so that a tight pharyngeal closure is achieved. Then, as usual, 2nd pharyngeal suture and 3rd adaptation suture through muscles. Insertion of 2 Redon drains and completion of the mucocutaneous anastomosis also in the upper area. Two-layer wound closure. Re-intubation to a 10 mm tracheostomy tube. Completion of the operation without complications. The patient is ventilated in the intensive care unit and should remain ventilated until the next morning. The patient should be instructed not to recline her head. The inserted nasogastric tube remains in place for 10 days, after which an X-ray gruel is taken and, if there is no fistula, the patient's diet is slowly built up. Please give antibiotics for 3 days, Unacid 3 g every 8 hours.