First, pharynxcopy and larynxcopy again: Confirmation of supraglottic to subglottic spread, tumor extends broadly forward into the anterior commissure. In CT, thyroid nodule rupture can be traced. Therefore, sterile draping after skin disinfection. Subsequent marking of an apron flap. This is lifted subplatysmally in a typical manner up to the level of the hyoid bone and submandibular gland. Then first modified radical neck dissection on the right: Dissection of the fat-lymph node packet from the sternocleidomastoid muscle. Then exposure of the cervical vascular sheath, internal jugular vein, internal/external carotid artery, vagus nerve, hypoglossal nerve and accessorius nerve. Several adherent lymph nodes cranial to the facial vein, clinically clearly suspicious. The facial vein is interrupted at the internal jugular vein. Nodes can be dissected from the internal jugular vein. Level II to V evacuation follows. Branches of the cervical plexus are preserved. Subsequently modified radical neck dissection on the left side: This is performed in the same way as on the right side with level II to V evacuation. Nodes are also clearly clinically positive cranially in level II as on the opposite side. They are not too adherent to the veins, which can be better preserved in this way. Subsequent laryngectomy: Skeletonization of the larynx in the same way on both sides. First, level VI lymph node preparation is removed and sent in separately. The infrahyoid muscles are then removed from the hyoid bone. This is cut downwards. This reveals a tumor breakthrough through the anterior commissure. Infrahyoid musculature is separated and the tumor is sent in as a frozen section marked with sutures. No tumor infiltrates towards the tumor-free side. Then release of the larynx, exposure of the superior chorda and dissection of the constrictor muscles on both sides. Outgoing vessels are ligated or bipolarly treated. Supraglottic soft tissues are completely removed up to the pharynx, below the hyoid bone. This is resected laterally on both sides. Due to the wide opening in the anterior region, the thyroid gland is partially resected on both sides, in the upper pole area. Several nodes are resected on the left side. The thyroid gland is repositioned by means of multiple re-stitching. The trachea is exposed, opened in the second intercartilaginous space with the incision directed cranially. Partial epithelialization of the trachea. Re-intubation, placement of a laryngectomy tube. Then opening of the larynx cranially, at the level of the epiglottis. Then release the larynx, leaving a distance of at least 1.5 cm to the tumor on all sides. Removal of the specimen. The larynx is marked with sutures and sent in as a frozen section. Complete removal of the tumor, cranially, caudally and basally. In conjunction with the previous marginal specimen, R0 situation. Subsequently, extensive irrigation of the wound area with H2O2 and Ringer's solution, careful hemostasis. The median myotomy is performed with the least possible mobilization of the soft tissue between the trachea or oesophagus, over approx. 3 to 3.5 cm. Subsequently insertion of an 8 mm Provox prosthesis in the typical manner, without complications. The medial part of the sternocleidomastoid muscle is detached close to the clavicle on both sides. The first suture is then used as an inverting suture to close the pharynx. A second inverting suture is placed over this, also with 3-0 Vicryl single button sutures. The constrictor muscles are sutured over this with 3-0 single button sutures and the suture is placed on top of the remaining hyoid bone. Careful hemostasis is then performed again. Irrigation with H2O2 and Ringer's solution. Wound closure in layers with insertion of a Redon drain in both sides of the neck. Epithelialization of the tracheostoma. Insertion of a 10 mm tracheal cannula. Conclusion without complications. Completion of the procedure without complications. Patient received Unacid 3 g intraoperatively. Please continue this antibiotic treatment for 2 days. Feeding via the previously inserted PEG tube until the 10th postoperative day, then gruel and, if necessary, a diet. Total cT4a cN2c transglottic laryngeal carcinoma. Radiochemotherapy should be discussed postoperatively.  