This is followed by bronchoscopic intubation. Then laryngoscopy and pharyngoscopy again: this confirms the preoperative findings, no infiltration of the pharynx. Now inject a total of 15 ml Ultracaine 1 % with adrenaline. Skin disinfection and sterile draping. Then outline the infiltrated skin. A distance of 1 cm with resection of the skin island, which remains on the laryngeal skeleton. Outside the resection, a circular margin sample is taken, which contains skin and soft tissue. No tumor infiltrates here. Thus free in the area of the neck skin. The rest of the neck skin is then lifted in the form of a subplatysmal flap. Skin remains somewhat more fixed in the cranial area for blood circulation. Beginning with neck dissection on the right: exposing the sternocleidomastoid muscle, exposing the omohyoid and digastric muscles. Cranially there are tumor-infiltrated lymph nodes in level II. The facial vein is dissected and ligated. The hypoglossal nerve is exposed and preserved. Cervical vascular sheath is exposed, internal jugular vein, internal and external carotid artery are preserved. Vagus nerve is visualized and preserved. N. accessorius is exposed and preserved. The lymph nodes are then removed from levels II to V, whereby the branches of the cervical plexus are preserved. The superior thyroid artery is exposed and preserved. Subsequent neck dissection on the left side: Level II to IV are removed in the same way as on the right side. The thoracic duct is exposed caudally but not opened. Subsequent laryngectomy: mobilization of the laryngeal skeleton on both sides in the same way. Mobilization of the thyroid gland caudo-laterally. Exposure of the hyoid bone and detachment from the suprahyoid muscles. Exposure of the superior cornu and detachment of the pharyngeal constrictor and dissection of the piriform sinus. Subsequent entry into the larynx at the level of the epiglottis. Successive development of the larynx from cranial to caudal. The trachea was previously opened caudally and partially epithelized. Re-intubation and insertion of a ventilation tube. The larynx is then developed and set down. The larynx is sent as a complete preparation for frozen section. The tumor margins are then all free in the frozen section. Pharyngeal tube easily passable at the entrance area, therefore no myotomy necessary. Insertion of an 8 mm Provox prosthesis without complications. The pharyngeal tube is then sutured. The mucosa is sutured inverted in a first layer. In a second layer, the first suture is inverted by another inverting suture. The pharyngeal tube is then sutured. This is followed by irrigation of the entire wound area with H202 and Ringer's solution. Subsequent inspection of the neck skin and measurement of the defect. Measure the length of the pedicle. Mark the pectoralis flap in the appropriate size and at the appropriate distance on the right chest wall. Create a subfascial skin bridge on the pectoralis major flap. Then develop the pectoralis major flap successively by placing ........... sutures. The vascular pedicle was previously identified under the pectoralis major. Successive development of the flap along its pedicle up to the clavicle. Insertion of the flap under the skin bridge into the neck skin defect. Then suture the pectoralis flap into the skin defect and simultaneously epithelialize the tracheostoma. Closure of the neck skin with insertion of a Redon drain after careful hemostasis and repeated irrigation in layers on both sides. Subsequent mobilization of the thoracic skin and, after careful haemostasis and irrigation, low tension closure of this after insertion of 2 Redon drains. Insertion of a 10 mm tracheostomy tube without any problems. The procedure was completed without complications. Overall cT4a laryngeal carcinoma with invasion of the prelaryngeal skin and soft tissue. R0 situation, neck dissection on both sides of the suspicious cranial lymph nodes in level II on both sides. Postoperative according to the histological findings, at least RT, possibly RCT. Feeding via PEG tube for 10 days, then gruel and, if necessary, diet build-up. Continue antibiotics with Unacid for a further 1-2 days.