After appropriate preparation, the PEG is first applied by <CLINICIAN_NAME> and <CLINICIAN_NAME>. The PEG is inserted in the usual manner using the pull-through technique. The skin is then disinfected and infiltrated with local anesthetic containing adrenaline in the area of the right neck or the right half of the subsequent apron flap incision. Here, sharp dissection through the subcutaneous fatty tissue and the platysma with exposure of the front edge of the sternocleidomastoid muscle. This is exposed along its entire length. Then expose and skeletonize the digastric muscle and the omohyoid muscle. Now dissect the vascular nerve sheath starting caudally. Expose and protect the vagus nerve and the common carotid artery as well as the internal jugular vein up to ............................................... The large metastasis is then painstakingly dissected along the internal jugular vein to below the digastric muscle. Both the accessorius nerve and the hypoglossal nerve can be exposed and secured to the end. The metastasis can finally be dissected free from the vein and the entire resectate together with the neck dissection specimen of region II to V can be removed in toto. The last layers of tissue on the vein as well as a vein outlet supposedly located in the metastasis are examined using frozen section histology and reveal no tumor infiltration, so that a healthy dissection can be assumed. Therefore, the apron flap is widened on the left side and folded up to above the hyoid bone. This is followed by radical neck dissection on the left side. Here, the vascular nerve sheath is first exposed under the digastric muscle and distally at the level of the omohyoid muscle. The metastasis here encompasses the internal jugular vein and can thus just be separated from the common carotid artery and the bifurcation as well as from the internal carotid artery in a healthy layer. However, the hypoglossal nerve and the accessorius nerve cannot be preserved. The internal jugular vein is then removed caudally and cranially and the entire specimen, including the neck dissection section, is completely resected. The larynx is then released. The suprahyoid muscles are first removed up to the pre-epiglottic fat body on both sides. First release of the laryngeal skeleton on the left side. Dissection of the right thyroid lobe and ligation of the isthmus so that the right thyroid lobe can be folded laterally. Subsequently, separation of the muscular insertions of the constrictor pharyngis muscle from the thyroid cartilage. Release the piriform sinus. Same procedure on the opposite side. The upper trachea is then exposed on the first 5 tracheal clamps. Opening of the trachea between the 2nd and 3rd tracheal clasps and reintubation of the patient. The lingual epiglottis is then exposed submucosally up to its superior edge. There, the pharyngeal mucosa is incised and the epiglottis is turned ventrally. After releasing the epiglottis, one looks at the rather large tumor located on the left side in the area of the arytenoid region. This is first incised on the left side. The same is done on the right side. The larynx is then removed under the cricoid cartilage and dissected cranially. The tumor and the laryngectomy specimen are then removed in toto under visualization and the two pharyngeal incisions are joined together in the area of the esophageal entrance. During the subsequent inspection, the resectate appears to be somewhat closer to the right hypopharynx. Therefore, another resection is performed here, which is not sent for frozen section histology. Subsequently, marginal sections are taken from all sides of the remaining pharynx, all of which are found to be tumor-free by frozen section histology. Particularly in the caudal part of the pharynx with the transition to the esophagus, there is just enough mucosa left to allow primary closure to be performed. Subsequent myotomy of the constrictor pharyngis muscle. Implantation of the Provox voice prosthesis in the usual manner. Then resection of the 2 upper tracheal clips so that the trachea can then be drained directly. The pharyngeal suture is then applied. The first layer forms a continuous T-shaped Conley suture. The second layer above this is performed in a single button suture. Finally, Redon suction drains are placed on both sides. Folding back of the apron flap and multi-layer wound closure with completion of the mucocutaneous anastomosis in the area of the tracheostoma and reintubation of the patient onto a 10-gauge tracheostomy tube. End of the operation after sterile wound dressing and handover of the patient to anesthesia. Conclusion: Totae laryngectomy for a squamous cell carcinoma located mainly on the left side of the arytenoid region with primary wound closure. Radical neck dissection on the left side and selective neck dissection on the right. Primary voice rehabilitation by implantation of a Provox voice prosthesis and myotomy of the constrictor pharyngis muscle. PEG placement. Due to the pronounced metastasis, adjuvant therapy in the form of radiochemotherapy is certainly recommended.