After intubation, a microlaryngoscopy and oropharyngoscopy were performed again. The exphytically growing tumor in the area of the right tonsil region can be seen, passing over to the base of the tongue towards the valecula. The piriform sinus on both sides, the visible larynx and the base of the tongue on the left are unremarkable. Oedematous mucosa was probably noticed on CT. Now detailed consultation with the anesthesiologist regarding the intraoperative procedure. Due to the small mouth opening, the tumor can only be extirpated by splitting the lower jaw. Therefore, senior physician <CLINICIAN_NAME> from the maxillofacial surgery department will be informed later about the mandibular division. First of all, start again with the PEG placement. Very difficult insertion of the flexible esophagoscope into the upper esophageal opening. Due to the very narrow conditions, it is finally possible to enter the oesophagus. Advance into the stomach. Inconspicuous conditions there. Good diaphanoscopy. Puncture of the stomach and insertion of the PEG tube. This cannot be pulled through, so check again with the MLE tube. There is a snag in the area of the tube. The tube is therefore removed again from the cranial side. Careful insertion of the flexible endoscope again. The esophagus is unremarkable. No evidence of perforation, advancement into the stomach. No bleeding there either, unremarkable conditions. Another puncture of the stomach and now problem-free insertion of the PEG tube. Perioperative administration of Unacid i.v.. Continue this postoperatively. Now start of neck dissection on the right side with preparation for splitting the lower jaw. To do this, make a skin incision in the area of the lower lip, moving onto the chin, onto the submandibular region and finally into the scar for neck dissection from the earlobe to the supraclavicular region. Dissection of the subcutaneous tissue and exposure of the sternocleidomastoid muscle. Exposure of the internal jugular vein, the facial vein and individual smaller veins. Exposure of the vagus nerve, accessorius nerve, digastric muscle, posterior vena cava. Very difficult dissection of metastatically altered lymph nodes from the jugular vein in the cranial part. Further dissection of the posterior neck preparation up to the supraclavicular region. There, the preparation was removed and repositioned to prevent a fistula. Now dissection of the hypoglossal nerve and the submandibular gland. Dissection of the anterior neck preparation with exposure of the external and internal carotid artery as well as the superior thyroid artery and the facial artery. The submandibular gland is also removed. To do this, dissect from the facial vein towards the mylohyoid muscle and cut and ligate the excretory duct. Removal of the submandibular gland. Neck dissection is also carried out in regions I and II a and b. All lymph nodes in the area of the facial vein medial to the mandible are removed and also included in the preparation. Now call in <CLINICIAN_NAME> from the maxillofacial surgery department. He first fits a plate in the area of the lower jaw with eight screws. The lower jaw is then split in a staircase between the canine and the first molar. After opening the lower jaw, the muscles of the floor of the mouth are cut through and dissected in the direction of the tumor. Now very difficult resection of the tumor, initially in the area of the laternal tongue and the base of the tongue. Then further laterally into the upper retromolar region towards the hard and soft palate. Here, a large part of the hard and soft palate falls down to the uvula. Dissection of the tumor then in the depth of the pterygoid muscle. The tumor can be further detached here. It is now possible to remove the tumor in toto in the block with great effort. Circular marginal samples are taken and sent for frozen section. Result: All marginal samples are considered to be tumor-free, and the biopsy from the left valecula, which was also performed, shows no evidence of tumor. An A0 situation can be assumed. Now reposition the patient. Removal of the ALT. Then perform the neck dissection on the left side. Also make a skin incision on the front edge of the sternocleidomastoid muscle, from the earlobe to the jugulum. Dissection of the muscle, exposure of the internal jugular vein, the vagus nerve and the accessorius nerve. Dissection of the accessorius triangle after exposure of the digastric muscle, posterior vena cava. Dissection of the neck preparation caudally. Deposition supraclavicularly after repositioning. Finally, dissection of the facial vein, the external and internal carotid arteries and the hypoglossal nerve. Complete the anterior neck preparation, including the submandibular gland. Complete hemostasis with H2O2 swabs and bipolar coagulation. No more bleeding. Insertion of a Redon drainage, subcutaneous suture, skin suture and wound dressing. In this area. Now perform the tracheotomy. Y-shaped skin incision in the longitudinal direction. Dissection of the subcutaneous tissue, exposure of the infrahyoid musculature. Opening of the same in the area of the linea alba, exposure of the thyroid isthmus and the cricoid cartilage. Separation and transection of the thyroid isthmus. The trachea is now exposed and opened. Creation of a Björ flap. Opening of the trachea so that an 8 mm tube can be inserted without difficulty. Re-intubation of the patient and epithelization of the tracheostoma with non-absorbable sutures and simultaneous application of skin sutures in this area. Now the ALT taken from the thigh, which is sized accordingly, is fitted into the tumor resection area. Incision with several Vicryl sutures, initially in the area of the naso- and oropharynx. Very difficult conditions here. However, the flap now fits very well. Suturing in the area of the posterior pharyngeal wall, extending to the base of the tongue and the mandibular region as well as in the retromolar region. Very good fit of the flap. Now primary suture in the area of the floor of the mouth, both the musculature and the mucosa. Call in <CLINICIAN_NAME> from the MKG. He closes and sutures the lower jaw and reattaches the perforated plate with eight screws for fixation. Very good fit. Occlusion fits. Now suction of wound secretions in the neck area and exposure of the superior thyroid artery and a large neck vein, which are well suited for anastomosis. First anastomosis of the artery. The artery is first anastomosed at the end. There are several leaks, so that the anastomosis is first cut once again and in the second attempt an anastomosis is achieved under microscopic control. Very good flow in the area of the artery. No leakage of blood. Repeated flushing with heparin. Finding the venous limb of the flap and dissection of a jugular vein. Using the coupler, the two venous ends can be approximated and anastomosed end-to-end. Very difficult dissection. Repeated irrigation with heparin. The venous return flow increases significantly over time, so that the arterial limb functions very well. After performing the coupler anastomosis, venous return is also very good. Flap well perfused. Adaptation of the anastomosis in the neck area. Now again thorough hemostasis with H2O2 irrigation and bipolar coagulation. No more bleeding. Insertion of Redon drains, subcutaneous and skin sutures. Closure also in the area of the lower lip and chin. No bleeding at the end of the operation. Detailed consultation with the anesthesiologist. Repeated administration of Unacid. Please pass this on postoperatively, paying particular attention to abdominal problems due to the two PEG insertions. Detailed consultation with the anesthesia department. The patient is intubated and ventilated and transferred to the intensive care unit for monitoring. This is followed by the surgical report for lifting the ALT flap of <CLINICIAN_NAME>. After identification of the landmarks, doppler sonographic identification of the main perforator and three small secondary perforators. After measuring the graft configuration for soft palate and tongue base. Initial medial incision and separation of skin and subcutaneous tissue, visualization of the rectus femoris muscle, strictly subpartial preparation. Reliable identification of the muscle, visualization of the very strong main perforator, therefore limitation to the main perforator. Identification of the strong vascular pedicle. Complete cutting of the graft. This shows a purely fasciocutaneous graft. A relatively thin graft can therefore be lifted here. Completely recut, taking the fascia lata in the graft area with it. Careful protection of the main perforator, leaving a small muscle cuff in the area of the perforator outlet. Isolation on the vascular pedicle, exposure of the confluence of the veins, exposure of the strong artery. Protection of the ramus obliquus and, if the vitality of the graft is excellent, removal of the graft. Careful wound inspection, insertion of a 10-gauge redon drain and careful multi-layer wound closure. The graft is then implanted transmandibularly.