Preliminary consultation with the anesthetist. Insertion of the mouth guard. Inspection of the oral cavity and oropharynx, where a suspicious formation is seen in the area of the tonsils on both sides. On the left side, this is now relatively clear compared to the panendoscopy a few weeks ago, which is why a tumor tonsillectomy is performed on the left side. On the right side, a biopsy is taken from the tonsil. The tumor tonsillectomy and the biopsy of the tonsil on the right side both go to frozen section diagnostics. Surprisingly, both findings were found to be infiltration by a tonsillar carcinoma in the frozen section. Subsequently, resection in the area of the left tonsil, in the area of the anterior and posterior palatal arch and dissection down to the muscles of the pharynx. Significant resection in the area of the posterior palatal arch, where the frozen section also showed infiltrates of the tonsillar carcinoma. Here, new specimens are taken from the margins, representing the entire margins of the deposit including the deep deposit towards the pharyngeal muscle area. All findings are diagnosed as tumor-free in the frozen section. Creation of a palatal arch plasty. Perform a subtle hemostasis. Since no fatty tissue is exposed here, neck dissection of the left side should be possible without any problems. Then perform the tumor tonsillectomy after obtaining the frozen section on the right side. The tumor appears to be limited exclusively to the tonsil. Here too, resection is performed down to the area of the pharyngeal muscles. Representative marginal samples are then taken and also sent for frozen section examination. These marginal samples are also diagnosed as tumor-free in the frozen section. Creation of a palatal arch plasty. Subtle hemostasis is then also performed here. Repositioning of the patient to attempt PEG placement. This was performed without any problems up to the stomach. A hiatal hernia is suspected here. If the diaphanoscopy is not positive, the PEG tube is not inserted. In this case, the gastroenterology or surgical colleagues should insert the PEG. Decision to insert a nasogastric feeding tube for the postoperative phase. This works without any problems. The patient is repositioned for neck dissection on both sides: Start on the left side. The metastasis has broken through at the posterior edge of the sternocleidomastoid muscle with infiltration of the skin. Therefore, the incision was moved slightly dorsally and a skin spindle was cut around. At the dorsal edge of the resection, a sample was taken from the edge of the skin, which was still diagnosed as tumor infiltrated in the frozen section. Therefore, resection in this area and resubmission of frozen sections after renewed removal of marginal samples. Subsequently, further dissection and visualization of the cervical vascular sheath. It became apparent that the metastasis had completely infiltrated both the branches of the auricularis magnus nerve and the accessorius nerve from the deep cervical fascia, so that a modified radical neck dissection with partial resection of the sternocleidomastoid muscle and the accessorius nerve had to be performed. Displacement and, at the end of the operation, re-embedding of the auricularis magnus nerve in the sense of a neurolysis. Only the anterior edge of the sternocleidomastoid muscle remains to cover the cervical vascular sheath. Exposure, long-distance dissection and displacement as well as re-embedding of the vagus nerve at the end of the operation in the sense of a neurolysis. Subsequent further dissection of the entire lateral neck in terms of levels II, III, IV and V. Dissection of the cervical vascular sheath and here dissection of the anterior neck preparation. There are conspicuously enlarged lymph nodes everywhere. Exposure of the hypoglossal nerve and clearing of the hypoglossal triangle. All branches of the external carotid artery and internal jugular vein are spared. Displacement and, at the end of the operation, re-embedding of the hypoglossal nerve in the sense of a neurolysis. This results in a neck dissection of level I b up to and including V. The specimen is sent for histopathological evaluation. With a free marginal specimen in the area of the skin's edge, two-layer wound closure. Insertion of a Redon drainage. Transition to neck dissection of the right side. Here too, skin incision along the anterior edge of the sternocleidomastoid muscle. Dissection in depth in layers and exposure of the cervical vascular sheath. A larger metastasis can be seen in the area of the venous angle, which lies on the hypoglossal nerve and must be dissected away from it. Clearing of the hypoglossal triangle. Displacement and, at the end of the operation, re-embedding of the hypoglossal nerve in the sense of a neurolysis. Exposure of the cervical vascular sheath and long-distance dissection of the contents of the cervical vascular sheath with the vessels and the vagus nerve. Long-distance dissection of the accessorius nerve. Displacement and, at the end of the operation, re-embedding of the vagus nerve and accessorius nerve in the sense of a neurolysis. Clearing of the entire lateral neck preparation in the sense of levels II to V. Numerous suspiciously enlarged lymph nodes are also found here. After careful hemostasis, there is no further resistance on palpation. Again, evacuation of the anterior neck preparation and further subtle hemostasis. Irrigation of the wound. Two-layer wound closure. Insertion of a Redon drain. Application of a pressure dressing on both sides. Final consultation with the anesthetist. Completion of the procedure.