<CLINICIAN_NAME>: Before intubation, perform another tracheobronchoscopy: insertion of the 0° optics. Unobtrusive conditions in the area of the trachea and bifurcation as well as the visible main bronchi. Intubation by the surgeon and finally performance of an esophagoscopy with gastroscopy and insertion of a PEG using the thread pull-through method in the usual manner. This was successful without any problems. Good diaphanoscopy. Subsequent endoscopy of the hypopharynx and larynx. Inconspicuous conditions here. The previously described tonsil tumor is seen on the left. First of all, detailed consultation with the anesthesiologist regarding the further procedure. Then sterile wound covering. Carry out the neck dissection on the left: Skin incision on the anterior edge of the sternocleidomastoid muscle. Very pronounced metastases in this area. Dissection of the external jugular vein, which remains intact. Then dissection in depth. A metastasis is found directly there. The metastasis is cut around with part of the muscle. Dissection of the internal jugular vein in depth, which is later removed and ligated as part of the radical operation. Now the vagus nerve, the hypoglossal nerve, the external and internal carotid arteries are dissected in depth. Dissection of the posterior digastric venter muscle and very careful clearing of the accessorius triangle after exposing the nerve. Dissection caudally and anteriorly. Complete the neck dissection. Removal of the capsule of the submandibular gland. Now counter-resection from the transoral side. To do this, cut around the tumor in the area of the tonsil, passing over to the base of the tongue. Deposition of the tumor clinically in healthy tissue. Removal of the tumor specimen and removal of circular marginal samples. The marginal specimen is found to be still tumor-infested in depth and laterally in the frozen section. Due to this extension, a counter-resection must be performed from the cervical side. Now further dissection in depth. Protection of the carotid artery. Resection of the pharyngeal musculature extending to the base of the tongue and removal of the entire tonsil bed. Clinical incision far into the healthy tissue. Smaller branches of the external carotid artery are also cut and severed and the lingual nerve, which also runs deep through the area still affected by the tumor, is severed. Again, marginal samples are taken, which are now found to be tumor-free. The defect is now larger and can only be covered with a radial flap. Now first perform the neck dissection on the right side: To do this, make a skin incision on the anterior edge of the sternocleidomastoid muscle. Expose the muscle. Dissection in depth. Dissection of the internal jugular vein, facial vein, vagus nerve, hypoglossal nerve and accessorius nerve. Dissection of the external and internal carotid artery. Dissection of the posterior digastric venter muscle. Dissection of the accessorius triangle from caudal to supraclavicular. Dissection of the omohyoid muscle and removal of the lymph nodes from the anterior neck preparation and the venous angle while sparing the entire structures. Removal of the capsule of the submandibular gland. Extensive hemostasis with H2O2 swabs and bipolar coagulation. No more bleeding. Insertion of a Redon drainage. Subcutaneous suture, skin suture and wound dressing. Finally, perform a tracheotomy: make a longitudinal and star-shaped incision over the jugulum. Dissection of the subcutaneous tissue. Exposure of the infrahyoid musculature. Dissection of the thyroid isthmus. Exposure of the trachea. Insertion between the 2nd and 3rd tracheal cartilage. Formation of a Björk flap and creation of an epithelialized tracheostoma. After tumor resection, a radial flap is now inserted. See the surgical report <CLINICIAN_NAME>. <CLINICIAN_NAME>: After creation of the R0 resection using combined transoral enoral resection, defect coverage using a microvascularly pedicled radial flap from the left side: First removal of the forearm flap: Defect was previously measured, flap dimension with three-dimensional, multi-lobed dimensions 10 x 8 cm with regard to size expansion. Flap is recorded on the forearm. Subsequent application of a tourniquet. The flap is then trimmed and the skin incision made in the direction of the elbow bend. Lift the flap subfascially from the ulna to the radial side. Radial inclusion of the superficial venous system. This is integrated into the pedicle with subcutaneous tissue up to the crook of the elbow. Forearm mucosa nevertheless remains supplied with subcutaneous tissue. The radial artery and accompanying veins are removed, clamped and supplied distally and proximally using 4.0 Prolene puncture ligatures. The flap was then lifted off basally and successively towards the antecubital fossa, with smaller, outgoing vessels being treated using clips. Changed anatomical situation in the antecubital region. There is a very small radial artery as well as another artery further distally, which also enters the pedicle. The interosseous artery, brachial artery and ulnar artery were previously identified. The venous vascular system does not show a brachiocephalic vein, but a relatively large accompanying vein that opens into the brachial vein and a smaller vein above it belonging to the surface vascular system. This accompanying vein and 2 arteries are conditioned. The tourniquet is then opened. Good flow into the flap. Flap is placed on the 4 vascular structures. Treatment here using ligatures or 4.0 Prolene puncture ligatures in the area of the arteries or double treatment using clips. Flap is flushed with heparin. Flap arteries less than 1 mm or between 1 and 1.5 mm. In the area of the forearm, hemostasis and layered wound closure are performed. A full-thickness skin is typically removed from the groin area. After thinning, this is sutured into the forearm defect without tension. A Vacuseal dressing is then applied in the typical manner. Suction 75 mmHg. The forearm is immobilized in a splint using an elastic bandage. Defect covered with a radial flap: Radialis flap is inserted into the defect and successively sutured into place using 3.0 Vicryl single button sutures in the area of the pharyngeal side wall, base of the tongue and floor of the mouth. Tension-free suturing. Both sides of the neck are revised again after neck dissection with regard to the connecting vessels. The left side is selected as the connection. The radial artery and smaller accompanying artery are anastomosed with the terminal branch of the superior thyroid artery and a branch branch branching off from it using 9.0 or 10.0 ethilon sutures. Good venous return after opening the clamps. Subsequent exposure of the external jugular vein to the cranial side, where it divides. It is placed here and supplied proximally using clips. Venous outlets are conditioned, also venous outlets from the flap pedicle. Anastomosis is performed with 2.0 or 2.5 couplers. After opening the clips, venous return is also good here. Positive smear phenomenon. Flap pedicle is fixed with several sutures to prevent kinking of the vascular anastomoses. Subsequent irrigation of the wound area with Ringer's solution and careful hemostasis. Wound closure in layers on both sides of the neck with insertion of a Redon drain. The site of the Doppler check is marked. Repeated enoral check shows a vital and well-vascularized flap. Final consultation with the anesthetist. The patient is admitted to the intensive care unit for postoperative monitoring. Please continue the antibiotic treatment with Unacid started intraoperatively for 1 week. Please continue therapy with heparin perfusor 500 units per hour, also started intraoperatively, for 5 days. Feeding via the inserted PEG tube for 10 days, then if necessary build up the diet. Please monitor Doppler for 5 days according to the schedule.