First laryngoscopy and pharyngoscopy: The tumor extension is as already described, no midline crossing but displacement of the rhaphe. Thus indication to perform the above therapy, no changes. First transoral tumor resection: insertion of the mouth retractors and ligation of the tongue. The tumor is now macroscopically incised on all sides with a safety margin of 1.5 to 2 cm. Approx. 60% of the base of the tongue is resected just above the rhaphe. The posterior half of the left tongue body is also resected. The floor of the mouth is also resected, including parts of the submandibular gland, whereby the lingual nerve is preserved. Resection extends over the glossoalveolar groove. Push off the bone here. The anterior palatal arch and tonsil are also resected, the posterior palatal arch is largely preserved. The resection extends caudally to the hypopharyngeal entrance. The entire specimen is removed and marked with a suture. Send for frozen section. In the frozen section, all margins are tumor-free, no evidence of higher-grade or invasive carcinoma infiltrates. Therefore R0 resection. The lingual and facial arteries had to be ligated during the resection. Overall indication for coverage with radial flap. Neck dissection on the left, split skin removal thigh on the right (<CLINICIAN_NAME>): Transition to left neck dissection. Positioning of the patient. Take over the operation from <CLINICIAN_NAME>. Marking the skin along the suture with a pen. Skin incision, separation of the platysma, subtle hemostasis, exposure of the external jugular vein, which is preserved at the end of the neck dissection. Exposure of the auricularis magnus nerve, which is also preserved. Dissection on the anterior edge of the sternocleidomastoid muscle on the left under the fascia and further medially. Here on the cranial part, the accessorius nerve is exposed and preserved. Dissection and elevation of the skin flap. Further exposure of the most important anatomical structures of the neck such as the omohyoid muscle, hypoglossal nerve, hypoglossal nerve, free dissection of the VJI and its branches. Mobilization with dissecting scissors and forceps of the fatty tissue between the omohyoid muscle, VJI and anterior belly of the digastric muscle while protecting the vessels, which are later preserved for the anastomosis of the flap. Further dissection supported by magnifying glasses below the facial vein on the left side of the gl. submandibularis surface up to the edge of the mandible. Keep the facial muzzle branch out of the surgical area and hold it up by hacking the dissected tissue. Further careful dissection and mobilization of the salivary gland tissue at the posterior and anterior margins. The proximal part of the facial artery is encountered in front of the posterior digastric belly. This was dissected free, only branches to the submandibular artery were coagulated. The hypoglossal nerve became visible above the digastric sling. Coagulation of smaller veins. Anterior mobilization of the gland. The gland is now still partially attached to the excretory duct that was resected enorally during the tumor resection. After tightening the gland, the ganglion is removed, the lingual nerve is bluntly pushed aside, the remaining duct is exposed and removed together with the gland. This intentionally creates a defect in the floor of the mouth and later allows the blood vessels of the flap to be drawn in and the anastomosis to be made. Further removal of the level IIa and IIb lobes while sparing the accessorius nerve. Further detachment of the fatty tissue from the vascular-nerve sheath while sparing the ACI, ACC and vagus nerve. Further exposure of the branches of the brachial plexus up to the level of the junction of the omohyoid muscle with the sternocleidomastoid muscle. Removal of the neck preparation en block. After careful hemostasis, residual fatty tissue is included in the preparation. After the anastomosis, insertion of a Penrose drain to close the wound in layers. The PEG is now placed (<CLINICIAN_NAME> and <CLINICIAN_NAME>): Insertion of the flexible endoscope under constant air insufflation, whereby the esophageal mucosa is free on all sides and without irritation. In the stomach, air insufflation and visualization of a positive diaphanoscopy. Now PEG placement according to the thread pull-through method in the typical manner. Without complications. Now repositioning for tracheostomy (<CLINICIAN_NAME> and <CLINICIAN_NAME>): After infiltration of local anesthesia 10 ml Ultracaine 2% with Suprarenin added in the area of the planned skin incision between the cricoid cartilage and jugulum, also infiltration of the neck dissection side on the left. Then abjode and sterile draping of the adjacent areas. Marking of the landmarks and identification of the cricoid cartilage level and marking of the planned skin incision according to Kocher. Cut through the skin and subcutaneous tissue. Exposure of the prelaryngeal musculature and transection on the linea alba and exposure of the thyroid capsule. The pronounced anterior jugular vein was previously ligated. Then expose the cricoid cartilage and dissect under the thyroid gland using a clamp after exposing the lower pole of the thyroid gland. Then place Pean clamps and cut through the thyroid isthmus, followed by repositioning, first on the right and then on the left, in the typical manner. Exposure of the anterior surface of the trachea and opening of the trachea between the 2nd and 3rd cricoid cartilage. Then decision to perform a visual tracheotomy according to Deitmer. Epithelialization of the tracheostoma with 4 sutures and easy transfer to an 8 mm tube. Transfer for neck dissection on the right (<CLINICIAN_NAME>): Infiltration with local anesthetic Ultracaine 2% with the addition of Suprarenin along the planned skin incision after marking the landmarks and marking the curved skin incision. Cut through the skin and subcutaneous tissue. Cut through the platysma. The auricular nerve and external jugular vein had to be severed after they had been ligated. Exposure of the anterior edge of the sternocleidomastoid. Dissection and exposure of the omohyoid muscle up to the hyoid. Then expose the posterior digastric venter muscle and the hypoglossal nerve and protect them. Now further dissection on the underside of the sternocleidomastoid and exposure and protection of the accessorius nerve. Dissection of the internal jugular vein from caudal to cranial and exposure of the same, whereby bleeding occurs in the middle section at an outlet. This is treated several times with Vascufil vascular suture, followed by hemostasis. Dissection cranially to the base of the skull. Start mobilization of the level IIa lymph node down to the scalene muscles and up to the mastoid. Successive detachment at the cranial end and detachment from the internal jugular vein, then mobilization at the edge of the sternocleidomastoid and finally pushing through under the accessorius nerve, with protection of the latter, further dissection is carried out caudally and with protection of the plexus branches, with removal of the entire lateral neck preparation down to the plexus level. The dissection is performed while sparing the vagus nerve after its exposure and sparing the internal jugular vein and internal carotid artery. Now remove the medial neck preparation. To do this, dissect the abdomen of the submandibular gland, remove the capsule and detach the specimen down to the level of the superior thyroid artery. The hypoglossal nerve, vagus nerve, plexus branches and accessorius nerve, internal carotid artery and internal jugular vein were spared. Subtle hemostasis using bipolar. No more evidence of bleeding. This results in a modified radical neck dissection level II to V a with preservation of the internal jugular vein, sternocleidomastoid muscle and accessor nerve. Insertion of a Redon drain and two-layer wound closure. Subsequent removal of the radial flap: the defect is measured endaurally and the flap is marked on the left forearm in the appropriate, required extent and three-dimensional configuration, including the rejection of the pedicle. Flap length 11 and maximum 7 cm. First lift the flap from ulnar subfascial. Then extend the incision to the olecranon. Exposure of the superficial venous system with connection to the deep venous system Including the superficial venous system subfascially. Dissection of the flap also radially and subfascial elevation. Caudal exposure of the radial artery and the accompanying veins. Clamp off. Subsequent exposure of the radial artery pedicle with accompanying vein. Dissection up to the antecubital fossa. Exposure and connection to the superficial venous system. Two larger cephalic veins can be visualized as well as a radial artery with entry into the brachial artery in a typical manner. A very small radial vein can also be visualized as confluence. The radial artery is then removed when saturation is stable. This is treated with stitches. Successive elevation of the flap along the pedicle. Smaller vessels are treated with bipolar coagulation or clips. Lifting of the pedicle up to the elbow. Lifting including the superficial venous system. The entrance to the brachial artery is shown in the crook of the elbow. The interosseous artery is not severed. The two branches of the cephalic vein are then removed. Ligatures here. Subsequently, the radial artery is also removed and ligated proximally. Separation of the radial artery from the brachial artery. Here suture with 6-0 Vascufil. After removal of the flap, it is rinsed with heparin solution. The hand is always well perfused after removal of the flap. Hemostasis is performed on the hand. Primary closure of the wound in the elbow area up to the skin defect. Finally, a piece of split skin 0.7-0.8 mm thick is removed with the dermatome. This is worked into the defect. The cutaneous nerve to the lateral brachii, which was exposed and preserved during the elevation of the radialis flap, is also taken into account. Subsequent application of a Mepilex dressing with Octenilin hydrogel. Application of loose compresses. Wadding bandage. Fitting of a Cramer splint. Then wrap the hand in the Cramer splint using an elastic bandage. Hand always well supplied with blood. Saturation is almost always 100% at the end. Positioning of the arm. Now incision of the radial flap: First cut the digastric muscle and enlarge the tunnel enorally to a width of 3 QF. Then advance the caudal sutures. Insertion of the flap, first placing the caudal sutures and suturing the flap caudally. Then suture the flap in all other directions up to the cranial using 3-0 Vicryl single button sutures. Tension-free, complete defect coverage in all dimensions is achieved, including the base of the tongue, floor of the mouth, glossoalveolar groove, pharyngeal side wall and tonsil lobe in the area of the anterior palatal arch. The stalk is or was passed through the throat. The left side shows the superior thyroid artery, the external jugular vein and the facial vein. All vessels are conditioned. The vessels of the flap pedicle are also conditioned. The radial artery is anastomosed with the superior thyroid artery using 8-0 Ethilon single-button sutures. After opening the clamp, good arterial flow and good venous return. The external jugular vein is anastomosed with a branch of the cephalic vein. Coupler size 2.5 was used for this, the facial vein was anastomosed with the other outlet of the cephalic vein using coupler size 3. Good venous flow in each case after opening the clamp, smear phenomenon positive in each case. The remaining small radial vein is closed using clips. Subsequent very careful hemostasis. Irrigation of the entire wound area. The site is now free of bleeding. Closure in layers with insertion of a flap or Penrose drainage. The site suitable for Doppler sonography and flap control was marked using skin sutures. Finally, insertion or suturing of an 8 mm tracheal cannula. Another enoral flap check. This shows a well perfused flap. A hydrogel dressing was applied to the thigh. The procedure was completed without complications. Patient transferred to intensive care unit for monitoring. Please continue antibiotics, which were started intraoperatively, with Unacid for one week. Nutrition of the patient via the inserted PEG tube for at least 10 days, with gruel swallowing and, if necessary, diet build-up. Please leave the perfusor with 500 E heparin/hour running for 5 days as already started intraoperatively. Flap control for 5 days according to the scheme, clinically and by Doppler sonography. If necessary, initiate swallowing training after diet build-up. Overall cT3 tongue base oropharyngeal carcinoma on the left, clinically no clear lymph node metastases. Postoperative presentation at the tumor conference, adjuvant therapy depending on the final histology. Please keep the wound in the area of the radial lobe closed for 5-6 days.