First of all, MLE again: The tumor described appears, which extends slightly from supraglottic to nasoglottic, over the anterior commissure to the left and down to just under half of the left vocal fold. Therefore indication for the above mentioned surgery. First attempt at PEG insertion: Pre-mirroring of the esophagoscope into the stomach. Even after several attempts, diaphanoscopy could not be achieved, so that the PEG placement seemed too risky. A feeding tube is therefore inserted. Tracheostoma placement: The thyroid isthmus is exposed via the caudal end of the zigzag incision. This is clamped off and supplied using puncture ligatures. Enter the inter-cartilaginous space between the 2nd and 3rd tracheal cartilage. Creation of a wide-stemmed Björk flap. Now repositioning for tracheostomy and fronto-lateral partial laryngeal resection: injection of a total of 20 ml xylocaine 1% with adrenaline into both sides of the neck and prelaryngeally. Prelaryngeal zigzag incision leading into the tracheostomy. Expose the infrahyoid muscles. Push off the soft tissue. Splitting of the infrahyoid musculature. Section paramedian left through the perichondrium to the thyroid cartilage. Dissection of the soft tissue from the laryngeal skeleton on both sides down to the cricoid cartilage. Thyrofissure with the wheel saw, sawing out a triangle that begins just below the incision. This is followed by dissection of the perichondrium from the remaining thyroid cartilage on both sides. No tumor infiltrates as already described in the CT are visible here either. Entering the larynx cranially. Overview of the tumor. Overview also relatively difficult via direct view, so that the tumor is finally transected medially. The tumor can now also be seen with a good overview of its subglottic extension. The tumor is initially removed on the left with a safety margin of several mm on all sides, whereby the resection is also carried out slightly subglottically. Resection also includes 2/3 of the left vocal fold including the ventriculus laryngeus and parts of the pocket fold. On the right, the tumor was also macroscopically resected with a safety margin of several mm on all sides. Here, a clear part of the subglottic area was resected. The resection extends to the arytenoid cartilage, which is partially resected. The cranial pocket fold is also resected. Caudally, the upper edge of the cricoid cartilage is exposed. Both specimens are marked with sutures and sent for frozen section. Margin samples from the arytenoid region, from the interary region to the left and from the lateral and cranial sides are also sent in. Preparation on the left completely healthy. On the right, subglottic to cranial and in the arytenoid region not in healthy tissue. Also marginal specimen in the interary region with CIS and marginal specimen cranial with CIS, also marginal specimen in the arytenoid region with CIS. Therefore, a 5-6 mm wide strip is resected again subglottically, covering the entire mucosa from the left paramedian to the posterior wall. This is thread-marked to the frozen section. No more infiltrates in the frozen section. A resection is also taken from the cranial area with a subsequent marginal sample. No more infiltrates in the frozen section. A resection is taken from the interary area as well as a further marginal sample, which extends to the left arytenoid cartilage. Here, mild to moderate dysplasia, but no CIS. Another extensive marginal sample is sent in from the ary area, which again includes parts of the arytenoid cartilage and surrounding soft tissue. Still carcinoma in situ infiltrates here. Another marginal sample is therefore sent in. This includes all cartilage and soft tissue parts up to the upper edge of the cricoid cartilage up to the mucosa of the postcricoid region, which, however, remains intact. The remaining marginal sample is sent for final diagnosis. If this marginal sample is positive, a laryngectomy is probably unavoidable for oncological reasons. Mucosa from the postcricoid region is sutured to the cricoid cartilage with two 3.0 Vicryl sutures to improve epithelialization. Subsequently, remnants of the pocket ligament are fixed to the left side of the thyroid cartilage via a drill hole. The thyroid cartilage is readapted cranially via drill holes. Perichondrium with attached soft tissue is successively adapted with Vicryl 4.0 single button sutures until complete soft tissue closure over the cartilage is achieved. The infrahyoid musculature is then sutured over the perichondrium. The wound is closed in layers with epithelialization of the previously inserted tracheostoma. A 9 mm tracheostomy tube is then inserted. Neck dissection on both sides: Beginning with the right side: Curved incision in front of the sternocleidomastoid muscle. Exposure of the anterior border of the sternocleidomastoid muscle and dissection of the fat lymph node package. Exposure of V. jugularis interna, exposure of A. carotis communis, A. carotis interna, A. carotis externa and A. thyroidea superior. Visualization of vagus nerve, accessorius nerve, hypoglossal nerve. Successive development of the anterior neck preparation with visualization and preservation of the hypoglossal nerve and superior thyroid artery. Subsequent development of the dorsal neck preparation with preservation of the branches of the cervical plexus. In level 2, cranial lymph nodes clearly suspected of malignancy. Neck dissection is then performed on the left side: in principle, this is performed in the same way as on the right side. The structures mentioned are also visualized. Levels 2-4 are evacuated. Irrigation of the entire wound area on both sides and careful hemostasis. Wound closure in layers with insertion of a Redon drain in each case. Completion of the procedure without complications. Patient goes to intensive care unit for postoperative monitoring. Intraoperatively started antibiotic treatment with clindamycin should be continued for at least 1 week with 4 x 300 mg/die. Wait for final histology. If residual histology from the right arytenoid region is tumor-free, radiation therapy should be discussed postoperatively in the residual laryngeal region. In the case of extensive resection in the arytenoid region, dysfunction of the swallowing function and protracted swallowing rehabilitation are to be expected, so this should be initiated as early as possible. In addition, control MLE should be performed in approx. 3 months. If histology in the arytenoid region continues to show carcinoma, a residual laryngectomy cannot be avoided for oncological reasons. The patient should then undergo speech rehabilitation.