First tracheotomy and PEG insertion by <CLINICIAN_NAME>: Head positioning in a slightly reclined position. Entry with the laryngoscope and charging of the piriform sinus. Entering with the flexible gastroesophagoscope and advancing into the stomach. Air insufflation into the stomach and elevation of the upper body by approx. 30 %. Perform positive diaphanoscopy. PEG placement in the usual manner using the suture pull-through method without complications. Now repositioning of the patient. Injection of Suprarenin. Sterile wiping and draping. Horizontal skin incision over 2 cm just below the cricoid cartilage. Dissection of the infralaryngeal muscles. Split the infralaryngeal muscles in the midline and dissect down to the cricoid cartilage. Undermining of the thyroid isthmus and sharp transection of the isthmus after bipolar coagulation. Identification of the anterior tracheal wall. Creation of a visor tracheotomy in the 2nd to 3rd intratracheal fissure. Insertion of an 8-gauge cannula after epithelialization of the tracheostoma in the usual manner. Then tumor resection transorally by <CLINICIAN_NAME>: insertion of mouth retractor. Exposure of the tumor. The tumor is incised on all sides at a distance of at least 1.5 cm. This results in an almost complete hemiglossectomy. The sublingual gland is resected, as are larger parts of the floor of the mouth and larger parts of the base of the tongue. The preparation is sent in toto and thread-marked for a frozen section. Here all margins are healthy. Thus R0 resection. Subsequent neck dissection. The undersigned first performs the neck dissection on the left side after sterile washing and infiltration with local anesthetic containing adrenaline. This is followed by a skin incision along the front edge of the sternocleidomastoid muscle. Dissection of the platysma flap and fixation in the usual manner. Subsequent skeletonization of the vascular nerve sheath. Identification and protection of the hypoglossal nerve and accessorius nerve. Evacuation of regions II to IV. There is no caliber or other type of facial vein. Subsequent evacuation of region I after submandibulectomy. This already creates a defect in the enoral direction, where the flap will be inserted later. Dissection of the digastric muscle at its tendon. Subsequent skeletonization of the superior thyroid artery, which will later be used for anastomosis. Then transition to the operation on the right side. In principle, the same procedure is used here. There are no clinically manifest lymph node metastases on either side. Elevation of the radial forearm flap on the left by <CLINICIAN_NAME>: Palpatory identification of the distal radial artery. Marking of the flap borders (8 x 6 cm) on the distal forearm, proximal to the flexor retinaculum, with an S-shaped incision running proximally into the cubital fossa. Incision of cutaneous and subcutaneous tissue starting proximally. Identification and visualization of the venous confluence in the cubital fossa. Identification of the cephalic vein and dissection of the vein distally with integration into the radial graft margin. Identification of the ramus externus of the radial nerve and elevation of the radial portion, leaving the peritendineum of the tendons of the brachioradialis muscle intact. Subsequent ulnar incision down to the forearm fascia. Incision of the fascia and subsequent subfascial elevation of the ulnar edge of the graft up to the tendon of the flexor carpi radialis muscle. Care is taken to leave the peritendineum on the flexor tendons and to spare the ulnar artery. Identification of the distal radial artery and trial clamping with a vascular clamp. After 5 minutes with good oxygen saturation measured by pulse oximetry (measured on the index finger), the vessels are removed with subsequent ligation (Prolene 6.0). Successive detachment of the flap pedicle from the M. pronator quadratus and M. flexor pollicis longus with ligation of the outgoing perforators using a vessel clip into the cubital fossa. Exposure and protection of the radial nerve on the medial side of the brachioradialis muscle. Exposure of the brachial artery, V. mediana cubiti, A. ulnaris. First removal of the radial artery, then of two veins of the superficial venous system. Vascular ligation by means of a bypass ligature (artery) and vascular clip (veins). Subtle hemostasis in the area of the wound bed using bipolar coagulation forceps. Two-layer wound closure in the area of the proximal forearm. Defect coverage of the graft bed with split skin from the right thigh in the usual manner. Suturing of preparation swabs. Application of a wound dressing and a forearm splint. Completion of the graft lift without complications. After appropriate removal of the radial lobe graft, it is sutured in place enorally with a single button suture and the stem is passed through the defect outwards into the neck. The arterial anastomosis is then made at the superior thyroid artery. The venous anastomosis is made through a large cubital vein as an end-to-side anastomosis to the internal jugular vein. Insertion of a Redon suction drainage and an Easy-flow drainage. Wound dressing on the left after multi-layer wound closure. Completion of the mucocutaneous anastomosis in the area of the tracheostoma. Re-intubation of the patient. On subsequent inspection of the flap, the flap is vital. Arterial blood is present at the distal puncture. End of the operation. Transfer of the patient to anesthesia. Patient goes to the intensive care unit for postoperative monitoring. Please monitor the flap for approx. 5 days clinically or by means of Doppler monitoring. Feeding via the inserted PEG tube for 7 to 10 days, then diet build-up or swallowing training. Please continue antibiotics that were started intraoperatively or preoperatively for 1 week. Postoperative presentation at the interdisciplinary tumor conference after receipt of the final histology.