After intubation and preparation of the patient by the anesthesia colleagues, the first step is to determine the extent of the mass again. The partially exulcerated, coarse and clearly submucosal mass can be seen in the area of the left edge of the tongue. The glossotonsillar groove is reached, as is the base of the tongue. Deep infiltration of a good 1.5 cm. However, the tumor is well defined on palpation. On the right side, the oral cavity is unremarkable, as is the oropharynx including the vallecula and lingual epiglottis. The hypopharynx is clear up to the tips of the piriform sinus and the esophageal opening. Exposure of the larynx and the subglottic region: A superficial but relatively extensive tumor is visible, which is accentuated laryngeally in the left epiglottis and occupies almost the entire supraglottic slope. The aryepiglottic folds are barely free. On the left side, growth over the pocket fold onto the anterior commissure, but growth over the petiolus and the anterior supraglottic slope, also circumscribed on the right side onto the anterior commissure. Subglottically, the larynx is free. Likewise in the area of the remaining vocal fold level. Overall, clear progression of both findings compared to the previous description. Especially in the area of the supraglottic laryngeal carcinoma. Now demonstration of findings and case discussion with <CLINICIAN_NAME>. Due to the comorbidity and the extensive radiation field required, the surgical procedure is now confirmed. Laser resection of the supraglottic findings and transoral resection of the tongue margin/base of tongue findings. First turn to laser resection. Adjustment with the Steiner expansion tube. First resection of the epiglottis to obtain an overview. The lateral parts of the epiglottis are left on both sides to preserve the aryepiglottic folds, otherwise complete resection of the epiglottis. Now good overview recovery in depth. Taking the supraglottic findings up to the aryepiglottic folds. Development of the supraglottic region. Inclusion of the left pocket fold and the ventriculus laryngis. Also described as involvement of the right pocket fold and the laryngeal ventricle. Now obtain a good overview of the anterior commissure. To gain an overview, successive resection of the tumor, starting with the epiglottis. This is followed by the main tumor portion, leaving the portion in the anterior commissure. This shows that a further tumor cone is also extending towards the thyroid cartilage in the area of the anterior commissure, but is not infiltrating it. Therefore, a complete post-resection is formed. Resection of the supraglottic region down to the thyroid cartilage and complete removal of the tissue down to the perichondrium. Circumscribed resection of the tumor cones in the area of the anterior commissure. Good demarcation here. Safe conditions now also at depth. After resection of the tumor, macroscopically in sano, the entire tumor is now completely covered with marginal specimens. In addition, multiple samples are taken from the anterior perichondrium to rule out cartilage infiltration. Also biopsy of cartilage material. The frozen section diagnosis for the invasive carcinoma now shows an R0 situation. A highly circumscribed CIS is seen in two places in the area of the anterior commissure in the marginal area, so that transoral resection of both areas and renewed marginal sampling is performed. This is now tumor-free tissue without high-grade dysplasia. This is followed by transoral resection of the tongue margin/base of tongue tumor: the tumor is cut around with a safety margin of approx. 1.5 cm. Palpation in depth clearly in sano. Resection up to the base of the tongue is necessary. In the region of the floor of the mouth, a cone is visible over the submandibular gland, extending towards the floor of the mouth. Removal of the gland. Complete resection of the duct. The tumor cone can be seen to extend clearly cervically in slender conditions, in depth clear in sano resection and removal of the tumor macroscopically in toto. Careful hemostasis. Complete coverage of the tumor with margin samples. These are completely diagnosed as tumor- and dysplasia-free in the frozen section diagnostics, so that after a renewed discussion of the case and findings with <CLINICIAN_NAME>, the neck dissection is dispensed with at this point due to the clear depth towards the floor of the mouth and the simultaneous impracticability of the neck dissection. Only the indicated PEG insertion and tracheostomy are performed. First PEG insertion: For this, insertion with the gastroscope under laryngoscopic control. Easy to see through to the stomach. This is inconspicuous and clear. With good diaphanoscopy, problem-free puncture of the stomach and insertion of the PEG tube using the usual thread pull-through method. The esophagogastric junction is somewhat uneasy in the sense of clear reflux esophagitis. Otherwise, the esophagus showed no suspicious findings. Finally, after obtaining all free edge samples, a plastic tracheotomy is performed. This involves a door-like skin incision. Cut through skin and subcutaneous tissue. ..................... cleavage of the infrahyoid musculature. Exposure of the cricoid cartilage. Exposure of the anterior surface of the trachea. Stitching of the thyroid isthmus and, due to the extensive laryngeal tumor, performance of the tracheotomy between the 3rd and 4th tracheal ring. Subsequent successive suturing of the tracheostoma. Re-intubation to a size 8 low-cuff cannula and completion of the procedure without any indication of complications. Patient receives intraoperative antibiotics with Unacid 3 g. Please continue this for 24 hours postoperatively. Conclusion: Intraoperative R0 resection of at least cT2 supraglottic laryngeal carcinoma and at least cT2 tongue margin carcinoma on the left. In the case of cN1 neck status and profound left oral floor defect, neck dissection should be performed twice in approx. 2 weeks. Leave the tracheotomy in place depending on the swallowing function in the case of extensive enoral defects. Postoperative pacemaker control as discussed preoperatively with the cardiology colleagues.  