Introductory consultation with the anesthesia department. Positioning of the patient. Repeated panendoscopy: The previously described tumor of the right tongue base is seen, which appears to extend to the oropharyngeal side wall as well as the glossotonsillar groove and the mandible. The mandible is certainly not infiltrated in the CT scan. However, the tumor extends somewhat laterally behind the mandible. Insertion of the oral retractor and removal of the arm, as flap reconstruction is to be expected here. The tumor is then removed from the anterior palatal arch paramedian to the uvula and dissected laterally and caudally. Dissection is carried out in the base of the tongue up to the midline. Dissection is carried out with an electric needle and scissors. It can be seen that the tumor extends to the lateral oropharyngeal wall as suspected and reaches the posterior mandible. Here the dissection extends into the fatty tissue. In the end, however, the vessels can no longer be controlled here, so that it is now necessary to switch to further dissection of the transcervical area. The patient is therefore draped and repositioned. Incision along the anterior edge of the sternocleidomastoid muscle. Dissection of the omohyoid muscle and the digaster muscle. Exposure of the cervical vascular sheath. This is then opened in an elongated manner. Long dissection of the vagus nerve. Exposure of the accessorius nerve. This is also dissected over a long distance, lifted out of its bed and dissected free in the sense of a neurolysis. Re-embedding of the nerves. Then insertion of retractors and preparation of the lateral neck preparation of levels II, III, IV and V. Here preparation of level I b with long-distance preparation as well as neurolysis and re-embedding of the hypoglossal nerve. Complete the anterior neck preparation so that the neck dissection of levels II to V is finally completed here. The posterior digaster venter muscle and the stylohyoid muscle are then dissected to allow wide access to the pharynx. It can be seen that the tumor can be palpated far ventrally in the tongue. Therefore, a submandibulectomy with ligation of the excretory duct was performed. Here, the hypoglossal nerve and the lingual nerve are dissected again over a long distance. The latter is also removed from its bed by neurolysis and re-embedded. Then open the pharynx and expose the tumor caudally. Subsequently, further dissection of the tumor combined transcervically and transorally. The tumor has a cone that extends deep into the base of the tongue and into the posterior floor of the mouth. Finally, under extremely difficult preparation conditions, with limited mouth opening, the tumor can be fully developed. Subsequently, marginal samples are taken from the palatal arch and the medial margin of the base of the tongue, the lateral margin and the anterior margin. It can be seen that tumor is still present in the lateral deposition area in the frozen section. The tumor extends here over the glossotonsillar groove to the alveolar ridge. The mucosa is pushed away from the horizontal part of the alveolar ridge and the ascending mandible. The entire flank medial to the ascending mandible is exposed. Grinding of the bone. Removal of marginal samples again. These also show renewed infiltrate of invasive carcinoma. Therefore decision to remove the last molar, to which the tumor now seems to reach. This represents a bridge reconstruction of the posterior molars, so that the bridge must be removed first. Then extraction of the last molar. Careful grinding of the lower jaw and the alveolus. Removal of a new marginal sample in front of the last molar, which is also assessed as tumor-free in the frozen section. This results in a current R0 resection of the tumor. In the meantime, lifting of the radial lobe in a typical manner. To do this, first assess the tumor resection defect. Modeling of an individual flap, which is then transferred to the distal forearm. Vascular check again. Start dissection on the ulnar side while protecting the long-distance dissection and displacing the ulnar nerve. Dissection of the distal end and another careful vascular check with pulse oximetry. A good ulnar peripheral supply can be seen here, so that after exposing the radial artery, this can be removed distally. Further development of the flap on the radial side. Dissection of the flap proximally with dissection of the proximal flap pedicle. Dissection is performed up to the elbow at the confluence of the deep and superficial venous system. The entire vein star is removed here. Separation of the artery. Subsequent modeling of the flap, which is painstakingly sutured in place transorally using sutures. Passing the vascular pedicle through the pharyngeal defect. After complete circular suturing, dissection of the neck vessels and exposure of the lingual artery. This is ligated to reduce bleeding. Exposure of the thyroid as well as the V. facialis and V. thyroidea media. The flap is anastomosed to these vessels with two veins and an artery. The venous anastomosis is performed with couplers, the arterial anastomosis with single button sutures. There is very good flow in all vessels. The flap appears pink. Therefore, insertion of wound flaps and subsequent two-layer wound closure. On the thigh, removal of split skin with a thickness of 0.8 mm with the dermatome with a width of 8 cm. The split skin graft is about 9 cm long. Then wound care using a non-adherent wound dressing. Treatment of the lifting defect of the radialis flap on the distal forearm and closure of the incision for vascular pedicle harvesting. Circular suturing of the split-thickness skin graft. Making several relief incisions in the skin graft. Then adjustment and application of a VAC dressing, which should be changed between the 5th and 7th postoperative day. Performing a permanent tracheostomy. Also extremely difficult preparation conditions with a short neck and high sternum. The incision is made as for the Kocher collar incision. Dissection in layers in depth after cutting through the platysma. Separate the infralaryngeal musculature and pretracheal musculature in the median line. Exposure of the thyroid isthmus. This is undermined and then severed after careful coagulation. Exposure of the anterior wall of the trachea. Exposure of the 2nd and 3rd cartilage clasp. Opening of the trachea between these two cartilage clasps and subsequent preparation of a Björ flap. Then circular suturing of the tracheostoma with mucocutaneous anastomosis. Insertion of a size 7 tracheostomy tube, which is fixed in place with sutures. Due to the difficult tracheostoma, the cannula should not be changed until the 5th postoperative day, but only suctioned out. Final consultation with the anesthetist. Transfer of the patient to the in-house intensive care unit.