At the beginning of the procedure, the trachea, the larynx transorally and via the tracheostoma are inspected again. A fixed arytenoid of the left side with a tumor extending into the vocal fold is seen, which then encircles the endolarynx and extends dorsally into the trachea. Here the tumor extends to the level of the tracheostoma. Due to the infiltration of the left arytenoid and the fixed vocal fold on both sides, a partial laryngectomy is not possible here, so that the indication for LE is established and confirmed. The patient is then repositioned for PEG insertion and a nasogastric feeding tube is inserted. Both are successful without any problems. During PEG insertion, the flexible instrument is inserted into the esophagus without any problems and the tube is advanced into the stomach under visualization. The patient has a history of abdominal surgery. Ceftriaxone was administered in advance as a prophylactic antibiotic. Diaphanoscopy shows positive paramedian on the left side below the costal arch. Then PEG placement with positive tenting phenomenon using the thread pull-through method. This is successful without any problems. Fixation of the PEG tube and bandaging. The patient is then repositioned and local anesthetic with adrenaline is injected preauricularly. Then separation of the prelaryngeal muscles via the larynx. Dissection onto the laryngeal skeleton. Dissection caudally after detachment of the infrahyoid musculature. Exposure of the anterior surface of the trachea. Exposure of the thyroid glands on both sides. When the muscles are opened precricoidally, a pronounced infiltration by the tumor can be seen, which is clearly growing into the thyroid gland in a paramedian direction. Therefore, the thyroid glands are released on the left side and a left hemithyroidectomy is performed. There is also an infiltration just in the area of the right thyroid gland and postcricoid. Representative marginal samples are taken. A positive marginal sample is seen on the right side, so that a partial resection must also be performed in the area of the thyroid gland. The removal of the marginal sample and its findings in the area of the anterior esophageal wall as well as in the remaining postcricoid region and the pharynx are unremarkable, so that an R0 resection can now be assumed. The radiology colleagues are now consulted again to assess the external CT images with regard to the final status. This revealed a cN0 status, which was also confirmed preoperatively in the ultrasound sonography. Due to the extent of the tumor growth locally on the larynx and in the area of the trachea, adjuvant therapy is certainly advisable for the patient. Accordingly, the patient does not appear to benefit from a lymph node resection as in a neck dissection on both sides, so that after a detailed intraoperative discussion of the findings, a neck dissection on both sides is not performed. The further procedure must then be decided at the interdisciplinary tumor conference depending on the final histopathological findings. Now mobilize the trachea by removing all tissue and cutting the pulmonary ligament. This allows the trachea to be mobilized sufficiently cranially. Insertion of 2 retaining sutures. Then closure of the pharyngostoma with single button sutures. A total of three-layer closure here. Then resection of the anterior edge of the sternocleidomastoid muscle. Before closing the pharyngostoma, perform the lateral myotomy on the left side. Now circular suturing of the trachea in the sense of a mucocutaneous anastomosis. This succeeds effortlessly so that the retaining sutures, which had been fixed to the hyoid bone in the meantime, can now be removed. A Redon drain is then inserted, followed by two-layer skin closure and application of a pressure bandage. Insertion of the size 9 tracheostomy tube, which should not be changed until the 5th or 6th postoperative day if possible. The patient is then transferred to the in-house intensive care unit. Due to the hemithyroidectomy on the left side and an epithelial body in the area of the postcricoid margin and thyroid gland on the right, regular calcium monitoring should be carried out here. The nasogastric tube was removed during the recovery phase. An X-ray pre-swallow examination should be performed on the 10th postoperative day.