Introductory consultation with the anesthesia department. Transoral tumor resection: insertion of rubber-reinforced wound blockers. Attachment of the tongue with a reining suture. Now a good overview of the tongue. The tumor is now resected far into the healthy tissue, at least 2 cm to all sides. This results in an almost complete hemi-glossectomy on the right, parts of the floor of the mouth as well as the sublingual gland and the sublingual/submandibular gland at the back are also removed. The lingual nerve is included in the resection. The tumor is thread-marked and sent for a frozen section. In the frozen section to all sides in healthy tissue, thus R0 resection. PEG insertion: Advancement of the flexible esophagoscope into the stomach. After creating a diaphanoscopy, placement of a 15 mm abdominal wall tube in a typical manner without complications. Fixation to the abdominal wall. After patho-histological confirmation of the R0 resection, transfer to neck dissection on both sides: skin disinfection both in the head/neck area on both sides as well as the left forearm and right groin. Injection of a total of 20 ml Ultracaine 1% with adrenaline in the area of both sides of the neck. Start of neck dissection on the left: Curved skin incision in a neck fold or along the sternocleidomastoid muscle. Subsequent exposure of the sternocleidomastoid muscle. Exposure of the omohyoid muscle, exposure of the digastric muscle and submandibular gland. The capsule is also removed in the caudal region. Subsequent exposure of the internal and external carotid artery, internal jugular vein and facial vein. Dissection and exposure, neurolysis and re-embedding of the hypoglossal nerve, accessorius nerve, vagus nerve, cervical artery and superficial branches of the cervical plexus. Successive clearing of levels II-IV. In the anterior neck area, the facial artery, the superior thyroid artery and the superior thyroid vein are exposed and preserved. Neck dissection on the right side: This is performed in the same way as on the left side. Level II-IV evacuation in the same way. In addition, level Ib excision including the submandibular gland and the sublingual gland. Both structures were resected as part of the tumor resection, here also with resection of the lingual nerve. Dissection and exposure, neurolysis and re-embedding of the hypoglossal nerve, accessorius nerve, vagus nerve and cervical nerve. The hypoglossal nerve is preserved here, as on the opposite side. Slightly enlarged lymph nodes on the right more than on the left, no significant signs of metastasis macroscopically. Removal of the forearm flap: marking of the skin island of approx. 5x8 cm. Apply a tourniquet. Cut around the skin island subfascially, incision up to the crook of the elbow in a curved manner. Exposure of the superficial venous system. Successive development of the radialis flap subfascially also from the radial side. Preservation of the antebrachial nerve if it does not run into the flap. Caudal clipping of veins. Exposure of the radial artery. This is clamped and supplied using 4.0 Prolene puncture ligatures, whereby a .................... suture to the skin area is also made in the flap area. The flap is then lifted subfascially under the vascular pedicle Outgoing vessels are clipped. Dissection up to the crook of the elbow. Exposure of the connection between the deep and superficial system. Outgoing veins are clipped. The artery is very thin. Therefore, dissection up to the division of the radial and ulnar arteries. Exposure of the confluence of the radial artery. Exposure of the cephalic vein. Now open the tourniquet. Good perfusion of the flap. Hemostasis again. Deposition of the flap on the cephalic vein, which is ligated cranially at the confluence of the radial vein, which is ligated cranially and shortly after the exit from the brachial artery, which is supplied by means of a clip and puncture ligatures. Subsequently good further perusion of the ulnar artery. Irrigation of the flap with heparin solution. Flap is voluminous overall due to the very thick subcutaneous layer. Subsequent insertion of the flap into the defect. Enlarge the tunnel again until it is three transverse fingers wide and one transverse finger high. The pedicle can be inserted through the tunnel into the soft tissues of the neck. Suture the flap, creating a slight tension through the thick subcutaneous layer. The flap is trimmed anteriorly in the area of the tip of the tongue. Complete defect coverage. The flap was partially sutured in place with sutures. Subsequent vascular anastomosis. Trimming of the superior thyroid artery and the radial artery. Suturing of these with 9.0 Ethilon. After opening the clamps, good arterial flow and good venous return. Then suture the cephalic vein at an outlet from the relatively thick facial vein. Select a 3 mm outlet for this purpose. The confluence of the radial vein is treated with clips. In the area of the facial vein, the cranial parts were ligated or supplied with clips. The distal superior thyroid artery was also supplied with clips. With good arterial flow, the alignment test shows good venous return. Subsequent careful hemostasis. Irrigation of the wound area on both sides. Wound closure in layers with insertion of a Redon drain on both sides. The wound in the forearm area was closed with full-thickness skin. A piece of full-thickness skin of the appropriate size was removed from the groin for this purpose. After mobilization of the skin edges and subcutaneous tissue, the groin is now closed in layers with minimal tension. The skin is closed using back-stitch sutures and a Redon drain is inserted. The forearm is closed in layers in the proximal area. The full-thickness skin from the groin is sutured into the defect. Complete closure of the defect. A Mepilex hydrogel dressing is then applied. Wölckchen compresses are then applied. The arm is then wrapped with absorbent cotton and a splint is fitted. Fixation of the arm to the Cramer splint with a loose bandage. Forearm always well supplied with blood after flap removal. Due to the situation of significant swelling in the tongue/oral cavity area, decision to perform a temporary tracheotomy: Kocher's collar incision. Dissection of the subcutaneous tissue up to the infrahyoid musculature. Division of these. Splitting of the very small thyroid isthmus after bipolar coagulation. Mobilization of the caudal skin. Subsequent creation of a small broad pedunculated Björk flap. Epithelialization of this in the typical manner with thibond sutures. Insertion of a 7 mm tracheal cannula. This is fixed with sutures. Slit compresses are applied to the inserted Redon drains, otherwise no further dressing. The site suitable for Doppler control was marked with a thread, right cervical. Completion of the procedure without complications. Patient goes to the intensive care unit for postoperative monitoring. Please continue intraoperative antibiotics for approx. 1 week. Also continue heparin therapy, which was started intraoperatively at 500 I.U./hour. Flap control according to the scheme for 5 days. Nutrition via the inserted PEG tube for approx. 7-10 days. Final consultation with the anesthesiologist.