Introductory consultation with the anesthetist. Induction of anesthesia. Transoral intubation by the anesthesia colleagues. Entry with the flexible gastroesophagoscope. Pre-viewing into the stomach. If the diaphanoscopy is good, a PEG is placed using the thread pull-through method. Application of a wound dressing. This is done without any problems. Sterile washing and draping. Perform the tracheostomy in the usual way. For this, vertical skin incision below the cricoid cartilage. Exposure of the musculature. Split the muscles in the median line and expose the thyroid isthmus. Dissection of the thyroid isthmus and exposure of the anterior wall of the trachea. Insertion between the 2nd and 3rd tracheal cartilage. Creation of a visor tracheotomy. Creation of a mucocutaneous anastomosis and transfer to an LE tube. Then positioning of the patient. Sterile draping of all relevant areas. Start with neck dissection on the right: skin incision in typical manner. Exposure of the sternocleidomastoid muscle. Exposure of the omohyoid and digastric muscles. Exposure of the internal jugular vein, facial vein, external jugular vein. Visualization of the internal/external carotid artery, superior thyroid artery, facial artery and lingual artery. Exposure of the hypoglossal nerve, vagus nerve, accessorius nerve and various branches of the cervical plexus. Displacement and, at the end of the operation, re-embedding of the hypoglossal nerve, vagus nerve, accessorius nerve and the branches of the cervical plexus in the sense of neurolysis. Clearing of the lymph nodes. There are positive lymph nodes in the level II area, which means that level II to V are cleared. Here too, several suspicious, slightly enlarged lymph nodes in the lower area. Insertion of a Redon drain. Two-layer wound closure. Application of a pressure bandage. Insertion of a McIvor mouth blocker and inspection of the tumor region. The tumor originates from the left tonsil and spreads to the soft palate on the left side and infiltrates the anterior and posterior palatal arch. The uvula is not affected. However, the tumor extends to the base of the uvula. The tumor extends caudally into the glossotonsillar groove and infiltrates the base of the tongue on the left side. Subsequently, combined transoral-transcervical tumor resection: First cut through the digastric muscle. Removal of the submandibular gland. The duct is ligated. The lingual nerve is initially preserved from the caudal side. The facial artery is exposed up to the top and left intact. Pharyngeal wall is dissected away from the vessels, vessels are dissected away from the pharyngeal wall using vessel loops. The tumor is then resected under internal and external control with a safety margin of at least 1.5 cm on all sides. The entire pharyngeal wall is removed. Resection extends cranially including the palatal arch and the soft tissue of the pterygoid muscles up to the hypopharyngeal entrance, laterally up to the alveolar ridge or mandible. The lingual nerve cannot be preserved due to the extent of the tumor and must also be resected. Resection extends forward to the floor of the mouth. The entire specimen is removed and marked with sutures. Additional marginal sample from the soft tissues superior basally. In the frozen section, both tumor and margin sample in healthy tissue. Thus R0 situation. Careful hemostasis. Measurement of the defect. This is approx. 11 x 8 cm. Neck dissection on the left. Skin incision in the usual manner on the anterior edge of the sternocleidomastoid muscle. Exposure of the sternocleidomastoid muscle. Exposure of the submandibular gland and the digastric muscle. Visualization of the omoyhoideus muscle. Exposure of the internal jugular vein. Dissection of the internal jugular vein. Dissection of the facial vein and the superior thyroid artery. Exposure of the accessorius nerve and hypoglossal nerve. Displacement and, at the end of the operation, re-embedding of the accessory nerve and hypoglossal nerve in the sense of a neurolysis. Removal of the neck preparation II a to V a while sparing the plexus branches and the cervical vessel sheath. Redon drainage. Two-layer wound closure. Application of a pressure bandage. Lifting of the radialis graft on the left forearm. To do this, the graft is first marked. Then the cephalic vein, radial artery and ulnar artery are marked. Incision of the skin. Exposure of the brachioradialis muscle. Exposure of the cephalic vein and the basilic vein. Exposure of the confluence between the deep and superficial venous system. Visualization of the superficial ramus, radial nerve. Exposure of the radial artery. Ligation and stitching of the radial artery. Separation of the radial artery. Lifting the graft from the tendon bed. Dissection of the pedicle up to the elbow and removal of the graft, leaving several venous outlets and preserving the interosseous artery. Marking of the radial artery. Flushing of the entire graft with heparin solution. Lifting of split skin on the right thigh and defect coverage on the left forearm. Sewing on swabs to establish contact between the split skin and the wound bed. Sterile wound dressing and application of a dorsal forearm splint. Insertion of the graft into the oral cavity and start suturing in the area of the soft palate. The graft fits in well. It lies loosely and is sutured in successively, partly around the teeth in the area of the alveolar ridge. In the base of the tongue, transoral suturing is not possible. Here, suturing must be continued transcervically. This is somewhat complicated due to the lack of visibility and swelling of the tongue. Finally, the graft can be sutured in completely. Finally, the oral cavity and pharynx area is filled with Ringer's solution. There is no secretion flowing into the neck area. Dissection of the facial vein, the external jugular vein and the superior thyroid artery as connecting vessels. In addition, an outlet is prepared on the facial artery for a third vein. Anastomosis of the arterial vessels and ultimately also the venous vessels. Unfortunately, even if venous return is initially very good, arterial perfusion still stops intraoperatively. The arterial anastomosis must therefore be reopened and it becomes apparent that an occlusion has occurred in the anastomosis area due to previous damage to the superior thyroid artery. The thyroid artery must be cut back until there is no longer so much arteriosclerotic plaque material in the vessel. However, there is also previous damage here and the arterial anastomosis must again be performed very carefully. The graft is now permanently well perfused and a Redon drain is inserted. Two-layer wound closure. Final consultation with the anesthetist. The patient is ventilated in the intensive care unit and should receive antibiotics for at least 24 hours. Usual flap checks.