Transfer of the patient to the operating theater and positioning of the patient. Introductory consultation with the anesthesia department. Carrying out the team time-out. Start of panendoscopy to determine the extent of the tumor again. Insertion of a nasogastric tube. Injection of suprarenin with lidocaine, sterile abjodation and draping. Start with the apron flap. If there is a large metastasis on the left side and a pharyngostoma may be present, the incision on the left side is not made symmetrically but slightly anteriorly. Dissection through the subcutaneous fatty tissue and dissection of the apron flap. Expose the submandibular gland on both sides. Now start with the neck dissection on the left side. Dissection of the omohyoid muscle. A soft tissue metastasis is revealed, which can also be histologically confirmed by frozen section. Careful dissection of the anterior margin of the sternocleidomastoid muscle and the omohyoid muscle. Locate the internal jugular vein and follow it. Dissection in level IV. As the vein runs through the large lymph node metastasis, the decision is made to ligate or puncture the vein caudally. This is done without any problems. Now successive further dissection of the metastasis bundle from the sternocleidomastoid. This is done sharply and parts of the muscle are removed. Exposure of the accessorius nerve. This can be preserved and is followed cranially. Sharp dissection of the metastatic bundle of the accessory and common carotid arteries and of the bifurcation. This is successful without any problems and both structures can be preserved. The metastatic bundle can be removed. Removal of the medial and lateral neck preparation. The vagus nerve as well as the hypoglossal nerve can be spared without any problems. Dissection of the lateral neck preparation on the left side reveals cerebrospinal fluid flow in the form of a chyle fistula. However, this stops after suturing. Transition to the right side. Here too, expose the anterior border of the sternocleidomastoid muscle and dissect caudally. Trace the omohyoid muscle to the digastric muscle. Exposure of the submandibularis in its entirety on the right side and exposure of the digaster muscle and dissection of the internal jugular vein. The internal jugular vein and all its branches can be preserved. The common carotid artery and the vagus nerve can also be spared. Suspicious lymph nodes are also found in regions Ib and II. These are successively dissected. Exposure of the accessory nerve and preservation of the same. Successive removal of the lateral neck preparation while sparing the plexus branches. Dissection of the medial neck preparation and preservation of the hypoglossal nerve. As on the left side, there is no evidence of increased bleeding. L Proceed to laryngectomy. Free preparation of the larynx medial to the cervical vascular sheath on both sides. Dissection of the prelaryngeal musculature and folding it down. Dissecting the cornu majus of the thyroid cartilage and exposing it. Incision with the scalpel and removal of the mucosa from the thyroid cartilage with the Freer. An attempt is made to preserve as much mucosa as possible on the piriform sinus on the right side. Enter enorally with the TE retractor and transcervically into the pharyngeal tube. Expose the epiglottis and pull up the epiglottis with the triangular clamp. Successive dissection of the pharynx and larynx in order to be able to remove the entire tumor. This extends further cranially than expected. This is successful without any problems. Removal of the trachea in the usual manner. Assessment of the remaining pharyngeal tube. The decision is made to perform a primary closure. Removal of marginal samples and hemostasis. Closure of the pharynx in the usual T-shape. Successive placement of the mucosal sutures after releasing the pharyngeal tube from the base of the tongue to enable tension-free suturing. Multi-layer closure of the pharynx. Stitching over the pharyngeal tube with the dissected prelaryngeal musculature. Suturing in TachoSil. There is now no evidence of increased bleeding, chyle flow or salivation. For this reason, two Redon drains are inserted, one on each side, and the neck is closed in two layers. Sewing in the tracheostoma. Application of a pressure bandage, which should press on the suture site, especially submentally. Antibiotic treatment with 3 g Unacid. After a final consultation with the anesthetist, the operation is completed. Antibiotics should be continued for at least one week. If the pharyngeal tube is thin, Provox has not been used. A P&P presentation should be made at intervals. Presentation of the patient at the tumor conference after receipt of the histology.