First of all, external inspection of the previously described, exulcerated tumor. Entry with the small bore tube under dental protection. Inconspicuous oral cavity and oropharynx. The base of the tongue and vallecula are also clear, as is the epiglottis. An exophytic, endolaryngeal tumor growth with complete displacement of the glottis or glottic entrance is now visible. However, the tumor does not exceed the aryepiglottic folds on both sides or the arytenoid region. Completely free hypopharynx, which can be visualized as far as the piriform sinus tips and the esophageal entrance. Insertion of a nasogastric feeding tube under visualization. The patient is then positioned and xylocaine with adrenaline is injected. The exophytic tumor growth is completely incised with a safety margin. Widening of the skin incision to lift an apron flap. Subplatysmal flap elevation is then performed first. Exposure of the sternocleidomastoid muscle, omohyoid muscle, submandibular gland and digastric muscle. All structures not infiltrated. Exposure of both sides of the internal jugular vein and facial vein. Exposure of the cervical vascular sheath. Exposure of the superior thyroid artery on both sides and the thyroid gland. Caudal visualization of the trachea. This is free of tumors caudally. If the tumor is externally on the right side, it can now be seen in depth on the left side. Paratracheal thyroid infiltration on the left. Paratracheal therefore subtotal thyroid resection, the vagus nerve is caudally caked into the conglomerate and is resected caudally. Right-sided circumscribed partial thyroidectomy, here with preservation of the superior thyroid artery on the left side. Ligation of the artery. Several lymph nodes conspicuous in number and size on both sides, but without definite malignancy criteria or perinodal growth. Clearing of level II to IV on both sides. Now visualization of the hyoid. Skeletonization of the larynx. Complete caudal exposure of the trachea. Entry into the trachea with resection of 2 tracheal clips, here macroscopically tumor-free externally. Complete mobilization of the larynx and the caudal tumour conglomerate. Entry pharyngeally at the level of the vallecula. Mucosa-sparing release of the epiglottis. Resection along the aryepiglottic fold with a safety margin of approx. 1.5 cm, also in the postcricoid region. Release the laryngeal skeleton while carefully protecting the esophagus. Performing the myotomy in the area of the upper esophageal sphincter and caudally in the area of the trachea to remove the larynx and the tumor in toto. On the left paratracheal side, there was a suspicious mass in the form of a lividly discolored, suspicious lymph node, corresponding to the CT diagnosis. Inspection of the specimen showed both the laryngeal tumor portion and the subglottic portion resected in sano on all sides with a safety margin of a good 1 cm. Somewhat unclear tissue changes or conspicuous changes in the caudal musculature. For this reason, a complete soft tissue margin sample was taken here, as well as imaging with margin samples of the entire tumor in the area of the mucosa and in the area of the tracheal abscess margin. Complete imaging of the skin resectate beforehand. All samples are diagnosed as completely tumor-free, meaning that an R0 resection has been achieved. The size of the defect is now measured, a skin defect measuring 11 x 7 cm in total. An anterolateral thigh graft is then harvested from the right. After marking the landmarks and doppler sonographic identification of the skin perforator and a strong secondary perforator, mark a spindle-shaped graft measuring approx. 12.5 x 7.5 cm. Medial incision. Exposure and securing of the rectus femoris muscle. Strictly subfascial preparation. Exposure of the perforators and the vascular pedicle. Performing the extension incision. Dissection of the vascular pedicle and release in the area of the intermedius muscle. A superficial musculocutaneous perforator course can be seen. Caudal removal of the vascular pedicle and elevation of the graft, taking the fascia lata with it. Inclusion of a narrow muscle cuff in the area of the perforators. Conditioning of the vessels and, if the graft is vital, removal of the graft. Careful wound inspection and, if the wound is dry, insertion of a 10 Redon drain and careful, two-layer wound closure. The graft is now inserted, initially tracheally. If the trachea is clearly set off caudally, there will be slightly increased tension even after mobilization, especially in the pectoral skin area. Here, mobilization of the skin as far as possible and insertion of the trachea anteriorly as described above under increased tension conditions. Later, successive insertion of the tracheostoma primarily through the graft. Microvascular anastomosis is then performed on the right side. Conditioning of the lingual artery. Perform the arterial anastomosis with 8-0 Ethilon; this is successful and sufficient. Immediate regular venous return via primarily one flap vein, therefore occlusion of the 2nd vein. Conditioning of the facial vein. Perform the venous anastomosis with the coupler system size 3.0, followed by regular pedicle perfusion, positive smear test and regular flap perfusion. Then complete incorporation of the graft after checking all wound regions. In the case of dry wound conditions, insertion of a 10 Redon drain here. Subsequently, careful, two-layer wound closure with fitting of the graft. Finally, with a vital graft and fully incorporated tracheostoma, reintubation to a size 10 low cuff cannula and completion of the procedure without any indication of complications. Conclusion: Intraoperative R0-resected, extensive cT4a cN+ laryngeal carcinoma with extensive peristomal spread. Postoperatively, please continue the intraoperatively started intravenous antibiotics with Unacid 3 g for 24 hours. If the wound is healing properly, perform an X-ray gruel on the 10th postoperative day. Special wound observation in the area of the tracheostoma in case of difficult tissue conditions. If the wound is healing properly, rapid administration of the urgently required adjuvant therapy.  