Initial consultation with the anesthesiologist. Dissection of the tumor, histologically confirmed as squamous cell carcinoma, with the spreading laryngoscope. Cleavage of the epiglottis in the midline and dissection along the vallecula. Dissection of the pharyngoepiglottic fold and successive resection of the tumor, including the pharyngoepiglottic fold, the aryepiglottic fold and the pouch ligament. In addition, the tip of the arytenoid cartilage is also resected so that ultimately only the vocal process and the muscular process of the arytenoid cartilage remain. Careful dissection outside the tumor manifestation. Removal of the tumor in the area of the arytenoid cartilage and directly in the area of the pouch ligament on the left side. Resection of part of the right-sided epiglottis as a resection and finally obtaining numerous marginal samples. Intraoperatively, one has the impression of having resected healthy tissue. The marginal samples are found to be tumor-free. Extremely difficult preparation conditions due to the size of the tumor. Several intraoperative consultations with the anaesthetist due to the localization of the tube and bleeding. Careful hemostasis. Advancement of the flexible endoscope into the stomach. Placement of a PEG after visualization of the diaphanoscopy in the usual manner. On reflection, the stomach and esophagus are unremarkable. Repositioning of the patient, initially for modified radical neck dissection on the right side. Apply local anesthesia along the anterior border of the sternocleidomastoid muscle. Abjode and cover the surgical area. Skin incision starting in the area of the mastoid tip, along the anterior edge of the sternocleidomastoid muscle up to the clavicle. Cut through the platysma. Exposure of the sternocleidomastoid muscle. Exposure of the auricularis magnus nerve. Displacement to the cranial side and at the end of the operation re-embedding of the same in the sense of a neurolysis. Exposure of the sternocleidomastoid muscle. Exposure of the external jugular vein, which is also preserved, relocated cranially and re-embedded at the end of the operation. Exposure of the accessorius nerve. Displacement and re-embedding of the accessorius nerve at the end of the operation in the sense of a neurolysis. Exposure of the common carotid artery, the internal and external carotid artery, the internal jugular vein, the vagus nerve and the hypoglossal nerve. Displacement and, at the end of the operation, re-embedding of the vagus nerve and hypoglossal nerve in the sense of a neurolysis. Exposure of the posterior venter of the digastric muscle. Exposure of the parotid gland. Removal of lymphatic and connective tissue in the area of levels IV and V. Here, the fascia of the deep neck muscles is dissected, the cervical plexus is exposed, displaced accordingly and spared. Dissection in a caudal direction. Exposure of the scalene gap. Exposure of the brachial plexus and the phrenic nerve. These structures are also spared. Deposition of the specimen supraclavicularly. Careful hemostasis. Exposure of the facial vein. Exposure of the superior thyroid artery. Exposure of the capsule of the submandibular gland. Removal of the lymphatic and connective tissue in the area of levels Ib, II and III. Intraoperatively, several smaller lymph nodes were found, but these were not suspicious for malignant infestation. Irrigation of the wound with water and hydrogen. Insertion of a redon drain. Wound closure in layers. Application of a pressure dressing. This results in a modified radical neck dissection of level Ib to V. The patient is then repositioned for neck dissection on the left side. A large level II, III metastatic mass extending into the caudal parotid gland is already visible. First mark the planned incision. Cut through the cutis and subcutis. Expose the platysma and cut it sharply. Expose the anterior edge of the sternocleidomastoid muscle and dissect it from caudal to cranial. Exposure of the omohydius muscle as the caudal border. From level III, an extensive, obviously capsule-overwriting metastatic comglomerate is visible, which extends into the subcutaneous level. The sternocleidomatoid muscle appears to be widely infiltrated here. Therefore, first mobilize the conglomerate and take a corresponding skin spindle in the area of the infiltration of the subcutaneous tissue. Insertion of the lower retractor. Turn to the jugular vascular sheath. Expose the internal jugular vein and the common carotid artery. Initial attempt to preserve the internal jugular vein. From level III, however, it becomes apparent that this is infiltrated over a large area by the metastatic conglomerate. Therefore, initially caudal dissection and double ligation as well as bypassing of the jugular vein stump. Dissect medially and cranially. Exposure of the digastric muscle. This also appears to be infiltrated by the tumor in the area of the posterior venter. The hypoglossal nerve located inferior to it also appears to be initially drawn into the metastasis. Extremely careful blunt dissection here. With great effort, it is finally possible to separate the nerve stump from the metastasis. The nerve is moved cranially in the sense of a neurolysis and can be spared during the operation. The facial vein and its branches must also be severed and ligated. Exposure of the carotid bifurcation and the internal and external carotid artery. Successive detachment of the metastatic conglomerate, which also infiltrates the caudal glandular pole of the parotid gland over a wide area. Parts of the oral branch must also be resected, as this is enveloped by the tumor infiltrate over a medium to long distance. In the meantime, the sternocleidomastoid muscle is also removed at the inferior margin. Cranially, the muscle is also detached at its point of attachment to the mastoid. The accessorius nerve can be separated from the metastatic conglomerate with difficulty. The metastatic conglomerate can be resected in toto after exposing, separating and legaturizing the cranial jugular part. The lateral neck preparation is then developed up to level V. The plexus branches are largely spared. At the end of the operation there is no evidence of chyle flow. Subsequent development of the medial neck preparation. Careful hemostasis using bipolar coagulation. Wound irrigation with H2O2 and Ringer's solution. Dry wound conditions at the end of the operation. Insertion of a 10-gauge Redondra ring. Subcutaneous suture with Vicryl 4-0 and skin suture with Ethilon 5-0. Repositioning of the patient for tracheotomy. Initial palpatory identification of the ring button level. Marking of the same. Creation of the skin incision in the form of an inverted T approx. 2 cm below the level of the ring node. Sharp transection of the cutis and subcutis. Exposure of the infrahyoid musculature. Exposure of the linea alba. Incision in the area of the linea alba and blunt lateral dissection of the muscle bellies. Exposure of the thyroid isthmus. Undermining of the same. Generous coagulation of the thyroid isthmus and insertion of the retractors. Subsequent identification of the button space between the second and third tracheal cartilage. Incision of the trachea and preparation of a wide-based styled Björk flap. Subsequent tension-free circular successive epithelialization of the tracheostoma. This was successful without any problems. Change to an 8-gauge high volume-low pressure cannula. At the end of the entire surgical procedure, another detailed discussion with the anesthesiologist in the sense of a final consultation and completion of the operation without complications.