<CLINICIAN_NAME>: PEG placement: supine position, positioning of the head. Enter with the laryngoscope blade and adjust the esophageal inlet. Then insertion of the flexible oesophagoscope and pre-scanning into the stomach. The esophagus is completely unremarkable. Further inspection of the stomach and pylorus including inversion. Unremarkable conditions on all sides. A PEG tube was then inserted using the thread pull-through method. There was a good diaphanoscopy. Tracheotomy: First injection of suprarenin/ultracaine mixture. Then sterile washing and draping. Palpation of the cricoid cartilage, thyroid cartilage and trachea. Curved skin incision between the cricoid cartilage and jugulum. Dissection in depth down to the musculature. Expose the midline and push the muscles sideways. Insertion of a retractor and exposure of the thyroid gland. This is relatively large and covered by very thick veins. Dissection of the upper and lower thyroid poles. Undermining of the thyroid gland. Then entering with Kocher clamps and clamping of the thyroid gland on both sides. Separation of the isthmus. Bipolar coagulation beforehand. Ligation of both thyroid lobes and exposure of the trachea. Now insertion between the 2nd and 3rd tracheal cartilage. Pushing these tracheal cartilages apart. The creation of a Björk flap is deliberately avoided as this tracheostoma is not intended to be permanent. Epithelialization of the skin in the sense of a visor tracheostomy. Insertion of an 8 mm Woodbridge tube. Skin suture at the lateral edges. Neck dissection on the right: Curved skin incision 2 cm below the mandible and T-shaped extension on the anterior edge of the sternocleidomastoid, this skin incision was previously discussed with <CLINICIAN_NAME>. Dissection of the platysma and exposure of the anterior edge of the sternocleidomastoid. Locate and expose the omohyoid. Insertion of a retractor. Then exploration of the submandibular gland. Locate the cervical vascular sheath. Finding and exposing the accessorius nerve. Then exploration of the digaster muscle. Finding and exposing the hypoglossal nerve. Then start of neck dissection with free dissection of the internal jugular vein from caudal to cranial, then transition to level IIb and clearing of this level while sparing the accessorius nerve. Then evacuation of levels III and IV while sparing the plexus branches. Level V is not evacuated. Evacuation of level IIa and level Ib as well as Ia, initially leaving the submandibular gland intact, which is later removed by <CLINICIAN_NAME> as part of the anastomosis. Exposure of all relevant vessels, external jugular vein, facial vein, superior thyroid artery, facial artery in preparation for the anastomosis. Neck dissection left: Curved skin incision 2 cm below the lower jaw, then T-shaped extension on the anterior edge of the sternocleidomastoid muscle. Separation of the platysma. Exposure of the anterior border of the sternocleidomastoid muscle, exposure of the omohyoid muscle, exposure of the submandibular gland, which is enlarged and hardened and looks tumorously altered. Involvement of <CLINICIAN_NAME> who evacuates level Ib including the submandibular gland and level Ia and creates a tunnel to the opposite side as well as an opening in the floor of the mouth enorally in order to pass the flap through here later. Now expose the internal jugular vein and locate the accessorius nerve, which is unusually deep and runs dorsal to the internal jugular vein. Clearing out levels IIb, IIa, III and IV while sparing the plexus branches. Then exposure of the vessels, external jugular vein, facial vein, superior thyroid artery. Hemostasis on both sides by means of bipolar coagulation and insertion of Redon drains. Resection of the palatal arch tumor on the right: On the anterior palatal arch with transition to the soft palate, there is a tumorous change that appears to be finely bumpy on the outside and does not infiltrate into the depths. First mark the edges of the incision with the monopolar, starting at the base of the uvula in the soft palate, past the alveolar ridge of the maxilla, taking the glossotonsillar fold with it. Now start resecting the soft palate with scissors and, if necessary, bipolar forceps. The mucosa with underlying tissue is resected without completely removing the soft palate. Then removal of the glossotonsillar fold. Removal of the tonsil and a tongue base. Hemostasis using bipolar coagulation. The specimen is sent to histology marked with a thread. The pathologist was also able to detect carcinoma in situ in the frozen section medially on the soft palate. Therefore, a good ˝ cm was resected here again and then a marginal sample from this area was sent laterally to the frozen section with suture marking. This frozen section of the marginal sample was then tumor-free. Hemostasis by means of bipolar coagulation. <CLINICIAN_NAME>: First transoral tumor resection: Initial oral floor resection: positioning of the head. Insertion of the mouth retractor. Tongue tie suture. Removal of the floor of mouth tumor, which is located in the anterior floor of the mouth and extends to the alveolar ridge. The tumor is incised with a safety margin of at least 1 cm on all sides. The periosteum is pushed away from the anterior bone. The muscles of the floor of the mouth are resected anteriorly if the growth appears to be deeper. Ductus Wharton is resected anteriorly on both sides. Removal of the tumor specimen and suture marking. Small focal infiltrates in the right tumor margin and at the junction of the alveolar ridge in the frozen section. Also carcinoma in situ in the area dorsal to the tongue. Therefore, another resection of a 1 cm wide resection dorsally towards the tongue and a wide resection laterally on the right up to the alveolar ridge. Due to the tumor resection, resection of the entire alveolar mucosa in the area of the incisors and canines as well as the first anterior molar is now indicated. These teeth must therefore be removed, which is done without complications. The entire alveolar ridge mucosa is then resected over the alveolar ridge. The mucosa is sent in with suture markings remote from the tumor. Similarly, marginal samples are sent in laterally on the right and dorsally from the tongue. No more tumor in the marginal specimens, thus R0 resection in the floor of the mouth. To confirm this, the bone in the anterior area is drilled back towards the alveoli with the large diamond drill, the alveoli are also drilled out and all mucosal parts are removed or drilled out. Then resection of the palatal/oropharyngeal sidewall carcinoma on the right (already included in the dictation by <CLINICIAN_NAME>). R0 resection at the end here too. Then laser resection of the carcinoma in situ of the left pocket fold: Insertion of the size C small bore tube. Exposure of the left pocket fold. A small bumpy area can be seen in which the preliminary biopsy was probably taken. This area is cut around broadly with a safety distance using the C02 laser 3 watt continuous wave with some soft tissue basally. The specimen is thread-marked and sent for frozen section. The frozen section shows carcinoma in situ infiltrates in the center, but peripherally free, thus also an R0 situation in the laryngeal region. Overall, R0 resection in all 3 resected tumors. Neck dissection on both sides and tracheotomy now follows. (already included in the dictation of <CLINICIAN_NAME>). Subsequent removal of the radial flap: the defect in the floor of the mouth is carefully measured beforehand. A flap with a maximum length of 9.5 cm and a maximum width of 6.5 cm is created. This is measured according to the defect. The defect is marked on the forearm in the appropriate size and shape. Then apply a tourniquet. Elevation of the flap first from the ulnar, then from the radial subfascial. Incision curved towards the crook of the elbow. Exposure of the superficial venous system. Exposure of the flap pedicle and brachioradialis muscle. Successive elevation of the radial flap. Distal exposure of the radial artery, here ligation with 4-0 Prolene. Successive elevation of the flap under its pedicle, smaller, outgoing vessels are supplied bipolar or closed with clips. The ulnar, interosseous and radial arteries can be visualized in the elbow area, as can the deep venous system and the connection to the superficial venous system. There are 2 larger veins here which can be used as an anastomosis. Deposition of the flap on 2 veins and 1 artery. Very good re-perfusion after opening the tourniquet. Sufficiently long re-perfusion time. The flap is then placed on the veins and the artery. The veins are ligated and the artery is supplied with a 4-0 Prolene puncture ligature. The flap is then rinsed with heparin solution. The flap is then sutured into the defect in the floor of the mouth: a wide tunnel is created from the left, through which the stalk is passed and brought over to the right side. The flap is successively sutured into the defect according to its shape and extent. Tension-free, complete defect coverage. Flap pedicle is passed through the tunnel to the right side. The veins and the artery are conditioned here. The superior thyroid artery is selected and conditioned as the anastomotic vessel. Suture to the radial artery with 8-0 Ethilon single-button sutures. After opening the clamps, good arterial flow and good venous return. Subsequent suturing of the cephalic vein to a terminal branch of the facial vein, which was previously prepared and conditioned. This is done with a size 3.5 coupler. The second venous vessel is then anastomosed to another small vein using a size 2.5 coupler. Good venous return and positive smear phenomenon in each case. Overall good flap perfusion, good arterial flow and good venous return. Careful irrigation of the wound area and hemostasis. Wound closure of each side of the neck and insertion of a Redon drain, which was fixed separately on the right side. Flap perfusion good to the end. A piece of full-thickness skin is now removed from the right groin in the typical manner. This is thinned out. After mobilization of the skin, the groin is closed in several layers with the insertion of a Redon drain. After thinning, the skin is inserted into the defect and sutured in place without tension. The cranial wound towards the elbow was closed in several layers in the typical manner. Subsequent application of a hydrogel-Mepilex dressing, loose application of compresses. Absorbent cotton dressing. Wrapping of the hand in the appropriate position on a Kramer splint using an elastic bandage. Hand is and was well supplied with blood at all times. The procedure was completed without complications. Patient goes to the intensive care unit for postoperative monitoring. Please continue antibiotics for 1 week, which had already been started intraoperatively. Flap control for 5 days according to the scheme using Doppler and clinically. Heparin perfusor 500 units/hour for 5 days. Feeding via PEG tube for 7 to 10 days. After that, diet build-up. Radiochemotherapy appears to be indicated for a total of 3 tumors and a bilateral N+ situation. Presentation in the interdisciplinary tumor conference.