First induction of anesthesia, endotracheal intubation via the existing tracheostoma by the anesthesia colleagues and positioning of the patient by the surgeon. Laryngoscopy was first performed using a Kleinsasser C-tube. This revealed a tumor that completely obstructed the entire laryngeal lumen from the median area of the aryepiglottic folds on both sides to the subglottic region. In addition, one has the impression that the tracheostoma has been inserted close to the tumor. Skin spray disinfection, application of local anesthesia cervically on both sides and around the existing tracheostoma. Skin ablation and sterile draping. Creation of a skin incision, transection of the subcutaneous tissue and the platysma and formation of a subplatysmal apron flap up to the level of the hyoid bone, which is then fixed in place using bridle sutures. The anterior edge of the sternocleidomastoid muscle is then exposed on the right side. Exposure of the anterior jugular vein and the right external jugular vein, which are ligated and cut. Dissection along the sternocleidomastoid muscle in depth. The branches of the cervical plexus are exposed in depth and spared. Now also expose the omohyoid muscle and dissect along the muscle to the hyoid bone. Identification of the N. accessorius and free preparation of the nerve from the neck preparation. At the junction with the internal jugular vein, the digaster venter posterior muscle is exposed and completely freed from the neck preparation. Expose the submandibular gland and dissect the digastric muscle up to the hyoid bone. Now focus on the internal jugular vein just above the omohyoid muscle. Dissection shows that 2 lymph node metastases measuring approx. 1 cm are firmly attached to the vein wall. On closer examination, the high-grade evidence of infiltration of the vascular wall is revealed. In consultation with <CLINICIAN_NAME>, it was decided to include the internal jugular vein in the neck preparation. For this purpose, expose the vein cranially just below the digastric muscle and caudally just cranial to the omohyoid muscle. Expose the common carotid artery, the carotid bifurcation and the vagus nerve along the entire course of the dissected vein. Now first remove the vein caudally and place 2 vascular ligatures on the vascular stump. The same procedure is also carried out cranially, sparing the hypoglossal nerve and the accessory nerve. Both nerves can be exposed and spared. The entire neck preparation is then removed from cranial to caudal, including the vein and constant bleeding control using bipolar coagulation forceps. The preparation is carried out with constant consideration of the nerves of the cervical plexus and the phrenic nerve on the scalene muscle. Removal of the neck preparation without complications. Hemostasis dorlt by means of bipolar coagulation and subsequent repositioning of the patient on the left side to perform the neck dissection. Dissection along the anterior border of the sternocleidomastoid muscle. Exposure of the accessorius nerve, digaster muscle and omohyoid muscle. Exposure of the cervical vascular sheath. Successive evacuation of the posterior and anterior neck preparation while sparing the above-mentioned structures and the plexus branches. In region IV, several suspicious masses were found on the left side, which were then removed with the specimen. Hemostasis there by means of bipolar coagulation. Subsequently, the skin of the already existing tracheostoma was cut circularly. Additional removal of the prelaryngeal fatty tissue subplatysmal. Both samples are sent for intraoperative frozen section examination, which results in the diagnosis of cancer-free findings in both cases. Due to the infiltration of the laryngeal skeleton at the level of the thyroid cartilage as demonstrated by computed tomography, it is decided to resect the prelaryngeal musculature in the laryngeal specimen. This is then cut caudally at the level of the cricoid cartilage and cranially at the level of the hyoid bone and removed in the laryngeal preparation. The hyoid bone is then skeletonized and the thyroid cartilage is skeletonized at its posterior edge on both sides. Care is taken to ensure that the prelaryngeal musculature with the thyroid cartilage is also removed in the preparation. Subperichondral dissection on the inner surface of the thyroid cartilage on both sides and maximum protection of the piriform sinus on its outer side. Subsequent exposure of the free epiglottis margin and median pharyngotomy. Dissection along the lateral edges of the epiglottis and the aryepiglottic folds on both sides. Maximum protection of the pharyngeal mucosa in the area of the piriform sinus from cranial to caudal on both sides. Transverse mucosal incision in the postcricoid area, joining the lateral incisions with this transverse incision and entering the region between the posterior wall of the trachea and the anterior wall of the esophagus. Dissection caudally in this layer. Repeated hemostasis using bipolar coagulation. Dissection of the thyroid gland from the side wall of the trachea on both sides. Dissection revealed that the tracheostoma had been inserted between the 1st and 2nd tracheal cartilage clasp and thus clearly in the area of subglottic tumor spread. Decision to remove the former tracheostoma in the tumor preparation. Exposure of the anterior tracheal wall caudal to the existing tracheostoma and incision between the 3rd and 4th tracheal cartilage clasp. Partial epithelialization of the new tracheostoma at its lower edge. Removal of the laryngeal preparation in toto, which is sent in thread-marked for intraoperative frozen section examination. In addition, the following edge samples are sent for intraoperative examination: Tracheostoma anterior margin, lateral tracheal wall left, lateral tracheal wall right, postcricoid mucosa, base of tongue midline, lateral pharyngeal wall right, lateral pharyngeal wall left. In the last 2 marginal samples and more precisely in their cranial part, CIS parts are then detected during the intraoperative frozen section examination. Thus, generous resection in this region and removal of 2 further marginal samples from the right and left cranial pharyngeal side wall, which were found to be tumor-free by the pathology colleagues in the intraoperative frozen section examination. Hemostasis there by means of bipolar coagulation. Cricopharyngeal myotomy in the typical manner. Subsequent 3-layer pharyngeal suture (thin submucosal connective tissue layer, striated pharyngeal wall musculature, residual prelaryngeal musculature). The pharyngeal suture is then reinforced with several pieces of Tachosil cut to size. Dry conditions, insertion of 2 Redon drains on both sides. Completion of the epithelialization of the tracheostoma at its cranial and lateral edges. Prior to this, the tracheal findings were shown to colleagues <CLINICIAN_NAME> and the joint decision was made not to use a Provox prosthesis due to the residual trachea being too far caudally. Two-layer wound closure. Application of a pressure bandage. The procedure was completed without complications. PEG placement was dispensed with in the absence of preoperative surgical information. However, this should certainly be carried out during the course of the operation, especially with regard to the necessary adjuvant therapy. Conclusion: Complete laryngectomy, modified radical neck dissection on both sides of region Ib-V with resection of the right internal jugular vein. Control of the pharyngeal suture by means of X-ray and suture pull on the 10th day requested, rapid presentation of the patient to our tumor board after receipt of the final histology for the purpose of planning further therapy. Due to a lack of information, a PEG was not used in this procedure.  