After induction of anesthesia and intubation via the tracheostoma, pharyngoscopy and throat inspection are performed again. This reveals a very dehiscent and inflamed tracheostoma. The pharyngoscopy/laryngoscopy reveals a tumor that completely occupies the endolarynx, but also has a clear, partially submucosal component that has already reached the mucosa in the area of the postcricoid and also in the area of the median wall of the right piriform sinus and slightly also of the left piriform sinus. The PEG system is now placed first, so flexible esophagogastroscopy is performed, followed by diaphanoscopy and placement of the PEG tube in the typical manner using the suture retraction method. Now proceed to the laryngectomy: an apron flap is formed for this, which goes into the old tracheostoma, where the severely inflamed skin is now partially resected. Now form the apron flap subplatysmal. Then turn to the neck dissection of the right side: Here several, clearly enlarged lymph nodes are visible, which are partially cemented together with the jugularis. The sternocleidomastoid muscle, the omohyoid muscle and the digastric muscle are thus exposed, then the accessor nerve is exposed and spared. The next step is to dissect along the internal jugular vein from caudal to cranial. Here, resection of the metastases directly cranial to the omohyoid muscle is quite difficult because the latter are connected to the jugular vein. The resection is ultimately successful. After complete exposure of the internal jugular vein, the lateral neck preparation is formed while sparing the vagus nerve, carotid artery, accessorius nerve and plexus branches. Several enlarged lymph nodes are also found here. Now follow the digaster anteriorly. Expose the submandibular gland. Tracing of the omohyoid gland and formation of the medial neck preparation while sparing the hypoglossal nerve and facial vein; the superior thyroid artery is also exposed and spared. Now proceed to the neck dissection on the left side: identical procedure here with only slightly enlarged lymph nodes. Expose the digastric, omohyoid and sternocleidomastoid muscles. Sparing of the accessorius nerve and formation of the internal jugular vein from caudal to cranial. Then dissect the lateral neck preparation while sparing the accessorius nerve and the plexus branches. Now turn to the medial neck preparation. Expose the facial vein and the hypoglossal nerve, which are spared, and follow the digastric muscle anteriorly. Expose and spare the submandibular gland. Then remove the medial neck preparation. Now the laryngectomy is performed: First separate the 2 halves of the thyroid gland from the trachea and then remove the omohyoid muscle and the cervical vascular sheath from the swallowing duct. The superior laryngeal nerve and its bundle are severed and ligated on both sides. The hyoid bone is now skeletonized in the cranial region and then the inferior pharyngeal constrictor muscle is detached from the lateral thyroid cartilage and dissected on the left side of the piriform sinus. Detachment of the latter from the inside of the larynx. On the right side, this step is omitted if a tumor is present. Now prepare the cranial side of the hyoid bone. To do this, place the left side transorally in the vallecula region and continue submucosal dissection along the lingual side of the epiglottis. Due to the suspicion that the tumor is very close, it is decided to open the pharynx in the vallecula after all. This is also carried out and it quickly becomes apparent that the laryngeal side of the epiglottis is also clearly affected by the tumor and that the distance to the healthy mucosa is therefore relatively small. Now first imaging of the left side. Here along the aryepiglottic fold, but then deviate to the lateral piriform sinus wall because there is also tumor infestation here. On the right side, proceed in the same way along the lateral side of the piriform sinus because the median side is affected by small tumor islands. In the postcricoid area, the pharyngeal suture can be reunited approximately 2 cm below the arytenoid cartilage region. Further submucosal dissection caudally until the cricoid cartilage is reached. Now change and attach the tracheal rings to the newly cut skin and then place the laryngeal preparation directly caudal to the cricoid cartilage. Due to the very extensive tumor, it is now decided not to send the entire preparation for frozen section examination, but to take additional frozen sections. For this purpose, the tracheal posterior wall and the base of the tongue are resected on the right side and then several frozen sections are taken from the trachea, the postcricoid region, the base of the tongue and the piriform sinus on both sides. All frozen sections are later found to be tumor-free. The cricopharyngeal muscle is then myotomized and a size 8 Provox prosthesis is placed in the typical manner using the retraction method. This is followed by pharyngeal suturing, which initially involves inverted sutures, then a 2nd layer of the submucosal layer and finally a 3rd layer of the muscle layer with the constrictor pharyngis inferior muscle. For additional reduction of a pharyngeal fistula, 2 TachoSil swabs are placed, 1x caudally and 1x in the area of the base of the tongue, more precisely in the area of the T-suture. Finally, the apron flap is retracted and attached to the tracheostoma, 2 Redon drains are placed and the wound is closed in two layers using subcutaneous and skin sutures. The patient goes to the IOI ward after waking up due to lack of capacity. Intraoperative administration of Unacid 3 g, which should be continued for 5 days. In addition, a nasogastric tube is inserted to serve as a splint.