Complete laryngotracheoesophageal clefts (types III and IV) are rare congenital anomalies that occur when the primitive foregut fails to separate into the tracheobronchial tree and the esophagus. This article summarizes a 10-year institutional experience with six infants who had type IV clefts, presents a modification of the authors' surgical approach, and identifies pitfalls in the management of these infants. Three of the six children are long-term survivors. The recognition of specific complicating issues leads to a standardized approach, which can result in successful repair and long-term survival.