Induction of anesthesia by the anesthetist. An attempt is first made to intubate bronchoscopically. This is not possible due to the large tumor masses. The bronchoscope cannot pass through the tumor masses and the glottis. Therefore withdrawal and decision for tracheotomy in LA. Ultracaine is injected in the tracheotomy area. Then a skin incision is made slightly below the cricoid cartilage, dissected in depth down to the prelaryngeal muscles. This is pushed to the side. Then dissection down to the thyroid gland. Exposure of the thyroid gland. Exposure of the thyroid isthmus. Dissection of the thyroid isthmus. Exposure of the anterior wall of the trachea and entry into the trachea between the 2nd and 3rd tracheal cartilage. Insertion of a laryngectomy tube and repositioning in preparation for surgery. Then sterile washing and draping. Creation of an apron flap in the usual manner, while protecting the platysma. Start with neck dissection/tumor resection on the left side. This reveals a very large metastasis that initially appears to be attached to the larynx and merges into the tumor per continuitatem. This metastasis is first detached from the cervical vascular sheath. It can be seen that the internal jugular vein runs directly into the metastasis. This must be cut off. The common carotid artery, the external carotid artery and the internal carotid artery can be detached from the metastasis, as can the vagus nerve. Most of the sternocleidomastoid muscle must also be removed, but the outer layers of the muscle can be preserved and the accessorius nerve also preserved, as there is clearly no tumor infiltration here. Exposure of the hyoid bone. Then release of the larynx and detachment of the cervical vascular sheath, also on the right side. Detachment of the suprahyoid muscles from the hyoid bone and opening of the pharynx at the exact point of the epiglottis. Pull out the epiglottis and incise the pharynx downwards along the free edge of the epiglottis. The tumor can be easily palpated macroscopically and the tumor is resected up to the posterior side of the pharynx, leaving a sufficient safety margin in the pharynx. Then release the piriform sinus on the right side and complete the tumor resection and laryngectomy by cutting around the pharynx and piriform sinus from the opposite side. Then the laryngeal preparation is also removed posteriorly below the cricoid cartilage so that a good tongue-shaped flap can remain on the posterior wall of the trachea. Now demonstrate the entire preparation on <CLINICIAN_NAME> and also on <CLINICIAN_NAME>. It is recommended not to perform a flapplasty as sufficient mucosal tissue is present. Due to the good safety distance, it is possible to take margin samples directly from the specimen without any problems. The specimen is completely covered by margin samples and cut around. The pathologist classifies everything in the frozen section as R0. Then insertion of a voice valve prosthesis in the usual manner by creating a tracheoesophageal fistula using the trocar provided for this purpose. The voice valve prosthesis is then inserted using the pull-through method and the edges are carefully rolled out. The Provox prosthesis is positioned approx. 1 cm below the tracheostoma. Now perform the pharyngeal suture in the usual way, starting at the top at the base of the tongue. Then switch to the distal area and place the 1st suture, then place the 2nd suture. Then complete the neck dissection in level V on the left side. Then perform the modified radical neck dissection on the right side levels II to IV using <CLINICIAN_NAME>. For this, the sternocleidomastoid muscle is further released, the accessorius is exposed, the hypoglossus is exposed, the neck preparation is released from the neck vessel sheath and removed. Now perform the 3rd safety suture, fixation of the constrictor pharyngeal muscle. Finally, incision and completion of the tracheostoma with formation of a mucocutaneous anastomosis. Two Redon drains were inserted and a two-layer wound closure was made. Please X-ray pap smear examination after 10 days, then, if there is no fistula, problem-free, step-by-step diet reconstruction and presentation of the patient to the tumor conference to plan adjuvant therapy.