First, after intubation via the existing tracheostoma, perform a pharyngo-/laryngoscopy: enter with the small bore tube under dental protection after inspecting the inconspicuous oral vestibule. An inconspicuous oral cavity including the floor of the mouth, tongue and soft palate is revealed. The oropharynx shows inconspicuous tonsil regions and posterior pharyngeal wall. The vallecula appears submucosally bulging, but there is still no exophytic tumor growth. The epiglottis is extremely displaced, there is an extensive, almost completely submucosal tumor that completely consumes the larynx. Careful inspection. The posterior wall of the hypopharynx and the lateral wall, including the piriform sinus, are completely free on the left, as is the free esophageal entrance; parts of the lateral wall of the hypopharynx are also free on the right. The piriform sinus is fixed and infiltrated by the tumor. Extensive extralaryngeal growth is palpated on the right side. Flexible esophagogastroscopy is now performed: an extensive scar is seen in the case of extensive gastrointestinal bleeding in 2010. With normal conditions in the gastric region and excellent diaphanoscopy, the stomach is now punctured without any problems and the PEG tube is inserted using the thread pull-through method without any problems. Inconspicuous esophagus on reflection. The patient is now repositioned. First of all, an apron flap is created by cutting around the old tracheostoma over a large area. Cut through the skin and subcutaneous tissue. Creation of the apron flap taking into account the platysma salt layer. Exposure of the sternocleidomastoid muscle on both sides. The extralaryngeal tumor growth can now be easily palpated. The thyroid gland is clearly enlarged but symmetrical and soft, and the infrahyoid muscles are not infiltrated. Initially start by detaching the tumorous process from the left side. To do this, first perform the neck dissection in the anterior region. Expose the submandibular gland. Exposure of the digastric muscle. Exposure and preservation of the facial vein. Dissection of the internal jugular vein. Exposure and preservation of the hypoglossal nerve. Exposure and preservation of the extremely strong superior thyroid artery. Exposure of the common carotid artery. The neck preparation is turned medially towards the tumor. This is followed by exposure of the thyroid cartilage horn. Release and ligation of the laryngeal bundle. Careful dissection and release of the piriform sinus. Exposure and release of the hyoid. This is clearly free on the left side. Dissection of the infrahyoid musculature. Dissection of the trachea on the left side. Left-sided resection of the thyroid isthmus. The pharynx is now entered between the thyroid cartilage and the hyoid, in the area of the left-sided vallecula, transition to the pharyngeal side wall. Free conditions here after inspection. Gradually widen the pharyngotomy and widen the mucosal incision. For a better overview, the lingual artery must be ligated and removed. It can now be seen that the epiglottis is also free on the left side. The vallecula is clearly tumor-free. Therefore, the mucosal incision is now extended along the aryepiglottic fold on the left and in the area of the vallecula. Successive release of the tumor. On the right side, the tumor appears to have at least contact with the hyoid, so the lateral right third is now resected. Now perform a parallel resection of the cervical sheath on the right side. The procedure is basically the same as on the opposite side. Expose the submandibular gland. Expose the digastric muscle. Exposure of the internal jugular vein. The facial vein moves towards the tumor and is removed after ligation. Careful dissection and preservation of the hypoglossal nerve. The superior thyroid artery also runs into the tumor conglomerate and is also removed after ligation. Exposure of the common carotid artery. Exposure of the prevertebral fascia. Medial and caudal, also relatively right-sided resection of the thyroid isthmus. The thyroid isthmus is preserved on the specimen, but is not infiltrated macroscopically. The former tracheostoma is now completely excised. This is also inflammatory in depth, but without evidence of direct tumor infiltration. Now, after complete mobilization and exposure of the cervical vascular sheath, the tumour is resected. Circumscribed right paralaryngeal open tumor, but with clear and safe separation from the soft tissue of the neck. Otherwise, regular soft tissue remains on all sides of the tumor. Complete resection of the tumor with resection of the right-sided piriform sinus. The mucosa of the posterior wall can be completely preserved, also free esophageal entrance, no postcricoid growth. A small, exophytic, ulcerated area can be seen in the area of the right-sided piriform sinus, otherwise completely submucosal tumor. Removal of the trachea, taking the tracheostoma with it, and removal of the tumor macroscopically clearly in sano. The mucosal margin samples are now imaged circularly. Moderate grade dysplasia, but no higher grade dysplasia or CIS was diagnosed in the postcricoid region and the right-sided hypopharynx. Completely free conditions on the left side. Therefore, no further resections were performed here. After inspection, the subglottic area was clear and wide. A Provox prosthesis is now fitted. Due to the inflammatory changes in the tracheostoma, conditions were somewhat more difficult, also due to the deep-seated trachea. The Provox prosthesis is inserted as cranially as possible. This is technically successful without any problems. The neck dissection is then completed. In principle exactly the same procedure. First on the left side. Exposure of the accessorius nerve. Release the accessorius triangle while carefully protecting the nerve. Release of level V with careful protection of the cervical plexus branches. Isolated ligation of a strong inflow to the thoracic duct. This can be easily visualized. Absolutely dry conditions here and no further measures. Complete exposure of the internal jugular vein beforehand. Careful wound inspection and turning to the opposite side. Level VI was removed en bloc with the preparation. Same procedure on the right side. Exposure of the accessorius nerve. Clearing of the accessorius triangle with careful protection of the nerve. Release of V a with careful protection of the cervical plexus branches. Ligation of the transverse cervical artery and coagulation of the right occipital artery. Careful wound inspection and hemostasis. Careful, two-layer pharyngeal suture with 3.0 mucosal suture, submucosal and inverting. Finally, good invasion of the 1st pharyngeal suture and tight conditions. Good mucosal conditions with preserved submucosal tissue. Mobilization of the detached thyroid gland is now performed, allowing a wide and large soft tissue mantle to be created on the pharyngeal tube. Suturing with 2.0 Vicryl. Final wound inspection. Insertion of a 10 Redon drain and cervical two-layer wound closure. Insertion of the tracheostoma. Clearly more difficult conditions here. Due to the inflammatory conditions in the area of the trachea and the relatively short tracheal stump, there is a slight tilting of the Provox prosthesis. Otherwise intact conditions on all sides. At the end of the operation, reintubation to a 10 mm tracheoflex cannula without any problems. Finally, also at the patient's request, removal of a left buccal atheroma, which has been present for many years. Also several atheroma-specific lesions distributed over the head. A curved skin incision is now made in the case of disturbing findings on the left buccal side. Cut through the skin. Excision of the directly subcutaneous mass, macroscopically and clinically clearly corresponding to an atheroma. Careful release strictly at the atheroma capsule. Therefore, protect the surrounding soft tissue. Meticulous hemostasis followed by careful, two-layer wound closure and completion of the procedure at this point without any indication of complications. Conclusion: Intraoperatively R0-resected cT4a cN2b glottic laryngeal carcinoma. Please perform a postoperative X-ray gruel swallow on the 9th postoperative day if the wound conditions are normal. In the area of the trachea, first wait for the wound to heal completely and then assess the Provox prosthesis.