Transfer of the patient to the operating theater. Followed by active patient identification. Consultation with anesthesia colleagues. Carrying out the team time-out. Two ECs in the blood bank. Induction of anesthesia and tracheo-bronchoscopy with 0° optics by <CLINICIAN_NAME> and <CLINICIAN_NAME>. This revealed the previously described finding of an exophytic mass of the entire vocal fold on the right side that extends subglottically and the anterior commissure could not be seen completely. Due to the extension, especially to the subglottic side, a partial laryngectomy, if necessary, was decided in the tumor conference. This is confirmed here. Now intubation by the anesthetist. Head positioning by the surgeon. Discussion of the skin incision with <CLINICIAN_NAME>. Skin disinfection and infiltration anesthesia in the area of the planned skin incision and 10 ml Ultracaine. Skin disinfection and sterile draping of the surgical site. Marking of the landmarks of the jugulum, incisura thyroidea, cricoid cartilage and the central chin. Draw the skin incision from the hyoid bone in a zigzag shape running caudally in a skin fold, just below the cricoid cartilage. Now make the skin incision using a scalpel and cut through the subcutaneous and cutaneous tissue. Expose the platysma. Dissection of the platysma and subplatysmal preparation. Exposure of the infrahyoid musculature. Enter the median plane and expose and dissect the thyroid cartilage as well as the ligamentum conicum, cricothyroid muscle and the ring button. Subsequent dissection of the perichondrium. An incision is made in the right paramedian using a scalpel. Then form a posteriorly pedicled periosteal flap to the right and left. Then open the thyroid cartilage paramedian on the left using a wheel. Prior to this, horizontal entry into the conic ligament with the scissors. Ensure that a sufficient piece of ligamentum conicum remains caudal to the thyroid cartilage for subsequent suturing. Now dissect alternately with <CLINICIAN_NAME>. Endolaryngeal lumen is exposed. This shows the exophytic tumor, which occupies the entire right vocal fold and extends into the anterior commissure as well as subglottically and into the morgue sinus. First, the tumor is dissected subperiosteally on the left side using a Freer and the tumor is placed at a safe distance in the anterior third of the left vocal fold. Subperichondrial dissection is then performed on the right side using Freer until just before the vocal process of the arytenoid cartilage. Ventrally, there is a questionable erosion of the thyroid cartilage, so saw it out as a triangular wedge on the right side. After further caudal dissection, the tumor can be completely resected down to the cricoid cartilage using a Freer and then using scissors down to the subglottic level. This is then thread-marked (vocal fold on the left, cranial sinus morgagni, caudal subglottic, dorsal posterior arytenoid and wound bed) for frozen section. The frozen section shows that the wound bed is just R0 and just reaches the resection margins in the area of the ary. For this reason, a resection is performed in the area of the wound bed between the cricoid cartilage and thyroid cartilage, which also goes to the frozen section. This is ultimately free. In addition, a resection and then a further marginal sample, dorsal ary, is again sent to the frozen section. This again shows CIS. Therefore, after demonstrating the findings to <CLINICIAN_NAME> and as the patient wanted to avoid a laryngectomy if possible and had no previous history of swallowing problems, another resection was performed. The vocal process of the arytenoid is also resected. This is repeated as a resection for the frozen section. Finally, a third marginal sample is taken by skeletonizing the arytenoid up to the interary area. This ultimately reveals an R0 situation in the frozen section. Targeted and intensive hemostasis is then performed. Between the frozen section breaks and due to the tumor extension to the subglottic area, a tracheotomy is performed. This involves exposing the bovine cartilage. Undermining of the isthmus of the thyroid gland. This is narrow and thin. Therefore, successive coagulation of the same and transection of the same and exposure of the anterior surface of the trachea. The skin was mobilized up to the jugulum and the incision widened again. Then, entry and identification between the second and third cricoid cartilage. Creation of tracheostomy sutures in the sense of caudal back-stitch sutures, as there are two in total, and two sutures cranially and reintubation. Now <CLINICIAN_NAME> recommends a selective neck dissection level II to IV due to the extent of the tumor in the sense of a transglottic carcinoma from supraglottic to subglottic. This is also performed during the frozen section break. To do this, mark the landmarks of the mastoid and sternocleidomastoid anterior margin on the right side and mark the skin incision. Then cut through the cutaneous and subcutaneous tissue and the platysma using a scalpel. Exposure of the sternocleidomastoid anterior margin. Exposure of the omohyoid muscle, which crosses over the jugular vein. Dissection on the sterno caudally and exposure and sparing of the accissor nerve. The neck is short overall and contains a lot of fatty tissue. Therefore difficult dissection conditions. Exposure of the course of the omohyoid muscle from caudal to cranial. Meticulous care is taken not to make any connection to the other surgical site. Exposure of the caudal belly of the submandibular salivary gland. Exposure of the digaster venter anterior muscle up to the omo. Exposure of the digaster venter posterior muscle up to the jugular vein. This is also visualized from caudal to cranial up to the junction with the digaster venter posterior muscle. Here the medial neck preparation is very voluminous. During careful dissection in this area, between the jugular vein and the digaster venter posterior muscle, i.e. medial/cranial to the internal jugular vein, there is an injury to an arterial vessel despite digital palpation. This was found not to be pulsating on palpation. Further dissection of this vessel revealed that it was a completely sclerosed internal carotid artery. Due to its kinking, in the sense of a vascular anomaly, it lies medially cranial to the internal jugular vein. There is no bleeding here as it is completely sclerosed. The vascular surgeon <CLINICIAN_NAME> is called in immediately. The pupils are equal at all times. The colleague confirms on CT that the internal carotid artery is completely occluded just above the bifurcation. She then completely transected the internal carotid artery. This shows that there is no reflux or flow. She ligated the cranial end and made several stitches around the caudal end using a prolene. This concludes the procedure. Now expose the hypoglossal nerve and the vagus nerve. Both are spared. Expose the facial vein and the cervical vein from caudal to cranial. The medial neck preparation is now removed. The superior thyroid artery is also exposed and spared. The vagus nerve and the accessorius nerve are exposed. The lateral neck preparation level V is left in place. Then, after insertion of a Redon and suturing of the same, two-layer wound closure. This was preceded by irrigation with H2O2 and Ringer's. Another meticulous inspection of the surgical site. This is completely dry, after still occasional targeted bipolar coagulation. Then two-layer wound closure using subcutaneous suture and cutaneous suture. Finally, after re-inspection of the laryngeal site and bipolar coagulation, supra-tip swabs are inserted. For closure, the edges of the larynx are very well adapted using 4.0 Vicryl with three sutures. The perichondrium suture is then applied. This is placed completely over the larynx and closes it completely and very well. The coniotomy is also closed. This results in a very good aspect. Insertion of a narrow flap between the thyroid cartilage and the infrahyoid muscles. This is now also sutured successively from cranial to caudal over the thyroid cartilage using single button sutures, so that this is very well covered and there is no indication of a fistula. Subcutaneous suture, including the platysma, and cutaneous suture. Intraoperative administration of clindamycin and reintubation with a seven-gauge Rüsch cannula. Application of a pressure bandage. Intraoperative until the end of the operation, pupils equal and narrow on both sides. Now end of the procedure. The patient goes to the intensive care unit for monitoring. Conclusion: Postoperative administration of Clindamycin 4 x 600 mg over 24 hours. Continue with pressure bandage. A nasogastric tube was placed. Ligation of the ACI on the right in a complete stenosis that had been present for 20 years in post-apoplexy on the right with hemiparesis on the left. Check of the neurological status. Please note the final histology. Presentation at the tumor conference and clarification of the procedure regarding the bronchial carcinoma.