Introductory consultation with the anesthetist. First placement of the nasogastric feeding tube. Then injection of local anesthetic with adrenaline and preparation of an apron flap. Dissection of the anterior border of the sternocleidomastoid muscle on both sides. First expose the cervical vascular sheath on the right side. The venous vessels in particular are extremely fragile. There is therefore a greatly increased tendency to bleed and the surgical conditions are very difficult. First dissection of the lateral neck preparation. Tearing of the internal jugular vein, which must be sutured over. The vessel can thus be preserved in its continuity. Dissection of the accessorius nerve. Displacement to the cranial side and re-embedding of the nerve at the end of the operation in the sense of neurolysis. The same procedure is used for the vagus nerve, but it is moved medially. Re-embedding of the nerve in the sense of a neurolysis. Same procedure for the hypoglossal nerve. Displacement to the cranial side and at the end of the operation re-embedding of the hypoglossal nerve in the sense of a neurolysis. Finally, dissection of the entire neck preparation of levels Ib, II, III, IV and V. Subsequent separation of the upper pole of the thyroid gland from the trachea and the laryngeal skeleton. Exposure of the hyoid bone. Transition to neck dissection on the left side. This shows a lymph node conglomerate in the area of the venous angle. Caudal exposure of the cervical vascular sheath. Here, too, the situation is the same as on the other side of the neck. With very fragile vessels, there is a significantly increased tendency to bleed here. The preparation conditions are also very difficult here. First attempt at long-distance dissection of the cervical vascular sheath. However, it then becomes apparent that the conglomerate is firmly attached to the venous angle and cannot be separated. Therefore, first expose the internal jugular vein cranially and caudally. This is first looped here. Dissect caudally and separate the vein. Stitch around the distal vein stump. Dissection on the common carotid artery. Dissection is performed cranially up to the carotid bifurcation. The conglomerate can also be seen here to be firmly fused to the external carotid artery. The adventitia is partially resected from the artery in order to separate the conglomerate in sano from the external carotid artery. The specimen can be easily separated on the internal carotid artery. The vagus nerve is also dissected over a long distance. This can also be separated from the lymph node conglomerate with difficulty, but nevertheless in sano. The nerve remains completely intact in its continuity. Same procedure for the hypoglossal nerve. Displacement and re-embedding of the vagus nerve and hypoglossal nerve in the sense of a neurolysis. The course of the accessory nerve must also be dissected sharply from the preparation in part, but its continuity is also preserved. Displacement and, at the end of the operation, re-embedding of the accessory nerve in the sense of a neurolysis. Finally, the entire conglomerate can be removed from the carotid artery and the jugular vein can be traced further upwards. Proximal removal of the internal jugular vein. Stitch around the proximal venous stump. The same is done with the facial vein. Finally, the entire conglomerate can be removed together with the lateral neck preparation. Touch up in the area of the accessorius triangle. Finally, this also results in a neck dissection of levels Ib to V. Here too, separation of the thyroid gland from the laryngeal skeleton. Dissection of the anterior surface of the trachea after cutting through the thyroid isthmus. Opening of the trachea between the 1st and 2nd cartilage clasp and extubation of the patient and insertion of a laryngectomy tube into the distal trachea. Further exposure of the hyoid bone. Finally, opening of the pharynx caudal to the hyoid bone. Successive detachment of the epiglottis and recutting of the epiglottis on the right side over the arytenoid cusps. Partial resection of the pharynx on the left side, where a scarred change is visible in the former tumor area. This entire area is also resected. Finally, the incision is brought together below the arytenoid hump. Further separation of the laryngeal skeleton from the pharynx. The pharynx was first removed from the thyroid cartilage margins. The preparation is then made up to caudal to the cricoid cartilage so that the preparation can be removed in toto. Removal of a marginal sample from the lateral edge of the pharynx on the left side, which is assessed as tumor-free in the frozen section. This shows an R0 resection after all other margins were far away from the tumor. Subtle hemostasis. Closure of the pharynx in three layers. Reconstruction of the infrahyoid musculature, which is also closed before the pharynx. Before closing the pharynx, first perform a paramedian myotomy on the left side. Also insertion of a voice valve prosthesis. This is done retrogradely without any problems. The Provox prosthesis is positioned at a typical location on the upper edge of the tracheostoma to be reconstructed later. Shortening of the medial parts of the sternocleidomastoid muscle at the base of the clavicle. Repeated subtle hemostasis. Insertion of a Redon drain into the neck on both sides. Fold back the apron flap, which is sutured in two layers. Application of a pressure bandage. Intubation of the patient onto a size 10 tracheostomy tube. Final consultation with the anaesthetist. Completion of the procedure without complications. The patient is transferred to the in-house intensive care unit for monitoring.