GRADE 实例

GRADE

ORIGINALSTUDY

MinilaparoscopicVersusConventionalLaparoscopic

Cholecystectomy

ASystematicReviewandMeta-analysis

VarshaThakur,MD,MSc,FRCPC ,ChristopherM.Schlachta,MD,FRCSC,FACS ,and

ShivaJayaraman,MD,MESc,FRCSC

Objective:Thisreviewbroadlyexaminestheimpactofminilaparoscopicver-susconventionallaparoscopiccholecystectomy.Theprimaryoutcomewasfailureofsurgicaltechnique.Thesecondaryoutcomesweretoexaminead-verseevents,cosmesis,lengthoftimetoreturntoactivity,qualityoflife,andlengthofoperation.

Methods:Fivedatabases,2conferenceproceedings,referencelistsofre-trievedarticles,andaWeb-basedtrialregistryweresearchedtoidentifyeligi-blestudies.Expertsinthe eldoflaparoscopicsurgerywerealsocontactedtoprovideinformationforthereview.Thissystematicreviewandmeta-analysiswereconductedinaccordancewiththeQUORUMguidelines.

Results:Eighteenstudiesmeteligibilitycriteria.Methodologicqualitywasunclearinmosttrials.Patientshavingaminilaparoscopictechniquehadhigherconversionratesthanpatientshavingaconventionallaparoscopictechnique[OR2.25(1.18–4.30)].Althoughminilaparoscopicsurgerieswereconverted,moreoftentherewasnotatrendtowardincreasedconversiontoanopentech-nique.Therewasatrendtowardfeweradverseeventsusingaminilaparoscopictechnique[0.57(0.31–1.04)],howeveritwasnotsigni cant.Cosmesiswasimprovedinminilaparoscopicpatientsat1month[meandifference 0.74( 1.09to 0.38)].Patientsreceivingminilaparoscopicproceduresreturnedtoactivityquicker[meandifference 0.74( 1.23–0.25)].

Conclusions:Furtherrandomizedtrialsareneededtodeterminewhetherminilaparoscopictechniquestrulyofferanyadvantages.Importantpatientoutcomessuchasfailureoftechnique,adverseevents,cosmesis,andqualityoflifeshouldbeemphasizedtodeterminewhetherthereisanybene toverconventionallaparoscopiccholecystectomy.(AnnSurg2011;253:244–258)

he rstreportedlaparoscopiccholecystectomywasperformedin1987byPhilipMouret.1Laparoscopiccholecystectomyispre-ferredtoopencholecystectomybecauseofimprovedpostoperativepainandperioperativemorbidity.2Asaresult,laparoscopiccholecys-tectomyisnowthestandardofcareinperformingcholecystectomy3whereasopencholecystectomyisreservedonlyforthemostcom-plicatedcases.3Conventionallaparoscopiccholecystectomyisper-formedusing4incisionsorports;one10–12-mmportintheum-bilicus,one5mm-or10–12-mmportinthesubxiphoidregionandtwo5-mmportsintherightsubcostalareaoftheabdomen.4Aslaparoscopictechniqueshaveadvanced,cholecystectomyhasbeenperformedwithsmallerincisionsand/orfewerports,broadlyreferredtoasminilaparoscopicsurgery.5,6Needlescopicsurgeryisasubcate-Fromthe FacultyofHealthSciences,HealthResearchMethodologyProgram,

McMasterUniversity,Hamilton,Ontario,Canada; DepartmentofSurgery,TheUniversityofWesternOntario,London,Ontario,Canada;and DepartmentofSurgery,UniversityofToronto,Toronto,Ontario,Canada.

Theauthorshavenocon ictsofinterestoranysourcesofsupporttodeclare.

Reprints:ShivaJayaraman,MD,MESc,FRCSC,UniversityofToronto,30The

Queensway,Suite221,Toronto,Canada,M6R1B5.E-mail:jayars@stjoe.on.ca.

C2011byLippincottWilliams&WilkinsCopyright

ISSN:0003-4932/11/25302-0244

DOI:10.1097/SLA.0b013e318207bf52

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goryofminilaparoscopicsurgeryusingthestandard4incisions/portsandinstrumentsthatarelessthanorequalto3mmindiameterversusthe5-mminstrumentsthatareusedtraditionally.7–9Reducedtrocarsurgeryisanothersubtypeofminilaparoscopicsurgerythatuseslessthan4incisionstoperformcholecystectomy.Othertermsforminilaparoscopicsurgeryincludeminiportormicrolaparoscopicsurgery10,11;boththesetermsareusedgenerallytoindicatealaparo-scopicprocedurewithsmallerincisionand/orfewerports.Morere-cently,singleportaccess,cholecystectomyhasbeenperformedusingasingletrocarattheumbilicus.12,13

Therationaleforusingsmallerinstrumentsand/orfewerinci-sionsistominimizetissuetraumaandimprovepostoperativepainandcosmesisforpatients.7,14Althoughsomeobservationalstud-ieshavefoundthatminilaparoscopictechniqueslengthenthetimeneededtocompletecholecystectomy,7otherstudieshaveshownthatminilaparoscopiccholecystectomyhasanoperativedurationthatiscomparabletostandardlaparoscopiccholecystectomy.5,9,14,15Minila-paroscopiccholecystectomyalsohasminimaloccurrenceofproce-duralcomplications(eg,bileductinjury).5,14,15Inthepastdecade,randomizedcontrolledtrialshavebeenperformedtoevaluatethesenewtechniquesinperformingcholecystectomy.Theobjectiveofthisarticlewastosystematicallyreviewthesetrialstodeterminewhetherminilaparoscopiccholecystectomyoffersadvantagescomparedwithconventionallaparoscopy.

Twoprevioussystematicreviewsevaluatingminilaparoscopicversusconventionallaparoscopiccholecystectomywereidenti edintheliterature.The rstreviewbyHosonoandOsaka16suggestedthatneedlescopicsurgerymaybeafeasibleapproachinperformingcholecystectomyinselectpatientsbecauseitcauseslesspostopera-tivepainandhasimprovedcosmesisoverconventionallaparoscopiccholecystectomy.However,thisreviewonlyincludedtrialsthatexam-inedneedlescopicsurgeryanddidnotevaluatethestudiesthatusedfeweraccessportsintheirmeta-analysis.Thevastmajorityofpa-tientswhoundergoconventionallaparoscopicsurgeryaredischargedwithinthesamedayofsurgerybecausepostoperativepainhasbeensubstantiallyimprovedoveropencholecystectomywiththeuseoflaparoscopictechniques.Thereforemeasurementofoutcomessuchaspainscoresanduseofpostoperativeanalgesiatoevaluatenewminimallyinvasivecholecystectomytechniquesarenotanimportantassessmentofnewertechnologies.Minilaparoscopictechniquesareperformedtoimprovecosmesis.Althoughcosmeticresultsmaybeimportant,amorecrucialoutcomemeasureistheevaluationofim-portantoutcomessuchasfailureoftechniquesuchastransitiontoconventionallaparoscopyoropenconversion.Similarly,bileductin-juryandotheradverseeventsareimportantoutcomestoconsider.ThesecondreviewbyMcCloyetal4evaluatedstudiesthatusedsmallerinstrumentsorfewerports,aloneorincombinationwitheachotherandconcludedthatminilaparoscopicsurgeryhadlimitedimpactonoutcomessuchaspostoperativepainandcosmesis,buthadhigherconversionratestoconventionaloropensurgerycomparedwithconventionallaparoscopicsurgery.Furthertrials17,18havebeenAnnalsofSurgeryrVolume253,Number2,February2011

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performed,thatwerenotincludedinthisreview,necessitatinganewandupdatedsystematicreviewonthetopic.

TABLE1.StudyEligibilityCriteriaforInclusionintheReview

TypesofParticipantsTypesof

interventions

AdultandPediatricPatientsRequiringEmergencyorElectiveCholecystectomyAllstudiesevaluatingminilaparoscopiclaparoscopiccholecystectomy,de nedas

1.needlescopic(4portswithinstruments≤3mmat2–3sites),

2.microlaparoscopic(4portswith2 3ports≥3mmand<5mm),

3.reducedtrocarreducedtrocarsurgery(using<4portswithinstruments≤5mmatoneormoresites).

Comparedwithconventionallaparoscopiccholecystectomyde nedas:

1.One10 12-mmportattheumbilicus,

one-5-mmor10–12-mmportinthesubxiphoidregion,andtwo-5-mmportsusedsubcostallyintherightupperquadrant.

Allstudiesincluding1ormoreofthefollowingoutcomes:

Failureofsurgicaltechnique(conversion)intotalFailureofsurgicaltechnique(conversiontoopencholecystectomy)Adverseeventsmortality

Adverseevents(intraoperativeandpostoperativecomplications)

1.Bleeding/hematoma2.Bileductinjury3.Bileleak

4.Commonbileductstones5.Bowelinjury6.Bloodtransfusion7.Incisionalhernia

8.Readmissiontohospital

9.PostoperativewoundinfectionCosmesis

ReturntoactivityQualityoflifeLengthofsurgery

Allrandomizedcontrolledtrials,includingpublishedandunpublishedstudies,willbeconsideredforevaluation.Trialsmaybeblindedorunblinded.

RESEARCHQUESTION

Theprimaryobjectiveofthissystematicreviewwastoexaminetheeffectsofminilaparoscopiccholecystectomyversusconventionallaparoscopiccholecystectomyashighlightedbythequestion:Whataretheeffectsofminilaparoscopiccholecystectomyversusconven-tionallaparoscopiccholecystectomyonthefailureofsurgicaltech-nique(conversionofsurgery)?Speci callywithinourprimaryobjec-tive,thereviewexaminedtheconversionofsurgeryinthe2groupstoanopentechnique.Thesecondaryobjectivesweretoexaminetheeffectsofminilaparoscopiccholecystectomyversusconventionalla-paroscopicsurgeryonadverseevents,mortality,cosmesis,returntoactivity,qualityoflife,andlengthofoperativeprocedure.

METHODS

StudyIdenti cationandSelection

Forthereview,5electronicdatabases(EMBASE,MEDLINE,Pubmed,TheCochraneCentralRegisterofControlledTrials,andWebofScience)weresearchedtoidentifytitlesandabstractsofallpossiblerandomizedcontroltrialsrelevanttothetopicofinterest.Alldatabasesweresearchedfrom1989to2009.Aslaparoscopictech-niqueswerenotdevelopeduntilthelate1980s,1thisensuredthatallpossiblestudieswerefound.Thefollowingtermswereusedto ndeligibletrials:“needlescopic”or“miniport”or“minilaparoscopic”or“microlaparoscopic”or“singleportaccess”and“cholecystectomy”or“gallbladderremoval”and“randomizedcontrolledtrials”or“con-trolledclinicaltrials”or“clinicaltrials.”Nolanguagerestrictionswereappliedtothesearchstrategy.Tworeviewers(V.T.&S.J.)in-dependentlyscreenedthedatabasesearchfortitlesandabstracts.Ifeitherreviewerfeltatitleandabstractmetstudyeligibilitycriteria(Table1),thefulltextofthestudywasretrieved.

Referencesofsystematicreviewsidenti edinthebackgroundsearchandreferencesofeligiblestudieswerehandsearched.Threeexpertsinminimallyinvasivesurgerywerecontactedtoidentifyanyrelevantunpublishedstudies.AbstractsoftheProceedingsoftheSocietyofAmericanGastrointestinalandEndoscopicSurgeonsandtheEuropeanAssociationofEndoscopicSurgeonswerereviewedfrom2000to2009forrelevantstudies.TheWorldHealthOrgani-zationInternationalClinicalTrialsRegistryPlatformSearchPortal(www.who.int/trialsearch)wassearchedforanyadditionalrelevantregisteredtrials.Thefullmanuscriptsofallarticlesidenti edinthesearchwerescreenedforeligibilitycriteriaby2reviewers(V.T.&S.J.)usingastandardizedform.Agreementbetweenthe2reviewersforinclusionofscreenedarticleswasmeasuredusingweightedkappaanddisagreementswereresolvedthroughdiscussion.

Typesofoutcomemeasures

Typesofstudies

Astudymustmeeteligibilityforall4componentsforinclusioninthestudy.

QUALITYASSESSMENT

Qualityofeacheligiblestudywasratedindependentlyby2reviewers(V.T.&S.J.)http://wendang.chazidian.compositescoringsystemswerenotusedduetoproblemswiththeiruse19andriskofbiaswasassessedasrecommendedintheCochraneHandbook,Chapter8.20Agreementbetweenthereviewersonassessmentofeachmethodologicalcomponentwasmeasuredusingaweightedkappa.Theriskofbiasforeachstudywasassessedonthebasisoftheprimaryoutcomeoffailureofsurgicaltechnique.Onthebasisofthemethod-ologyassessment,the2reviewersgaveeacheligiblestudyanoverall

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ratingofhigh,low,orunclearriskofbias.Appropriateallocation

togroupassignmentandconcealmentofrandomizationwereconsid-eredmoreimportantthanotherdomainsforminimizingriskofbiasinevaluatingfailureofsurgicaltechniqueandreviewersgavemoreimportancetothesedomainswhendecidingonoverallriskofbias.Agreementbetweenthe2reviewersonoverallriskofbiasassessmentwasdeterminedusingweightedkappaaswell.Disagreementswereresolvedthroughdiscussion.

DATAABSTRACTION

Tworeviewers(V.T.&S.J.)independentlyabstractedrelevantinformationfromeacheligiblestudyusingastandardizedform.In-formationaboutthecharacteristicsofthestudypopulation,details

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oftheminilaparoscopictechniqueusedandrelevantoutcomeswererecorded.Studyauthorswerecontactedtoclarifyabstracteddataandobtainpatient-leveldatatoensureaccuracyinthereview.Failureofsurgicaltechniqueintheminilaparoscopicgroupwasde nedasfol-lows:(1)transitiontoaconventionallaparoscopic,(2)conversiontoopentechnique,or(3)useofanextratrocar.Failureofsurgicaltech-niqueintheconventionallaparoscopicgroupwasde nedasfollows:(1)conversiontoanopentechniqueor(2)useofanextratrocar.Becauseconversionofaminimallyinvasiveproceduretoanopentechniqueisimportant,thiswasevaluatedasaseparateoutcomeinadditiontoevaluatingconversionsasde nedabove.Disagreementsbetweenreviewersregardingdataabstractionwereresolvedthroughdiscussion.

RESULTS

StudyIdenti cationandSelection

Usingtheoutlinedsearchstrategy,atotalof608citationswereobtainedforreviewoftitleandabstract.Ofthe608citations,556werenotrelevantand29wereduplicates.Fulltextoftheremaining23studieswasretrievedforreview;22werejournalarticleswhereas1wasaconferenceabstract.Clinicalexperts,reviewofproceedingsofSocietyofAmericanGastrointestinalandEndoscopicSurgeonsandEuropeanAssociationofEndoscopicSurgeonsandsearchingtheWHOclinicaltrialsregistrydidnotrevealanyfurthereligiblestudies.Hand-searchingthereferencesofprevioussystematicreviewsdidnotidentifyanyrelevantstudies.Identi cationandselectionofeligiblestudiesissummarizedinFig.1.

Ofthe23fulltextarticles,5studies24–28wereexcluded.Onetrialhadthewrongcomparatorgroup,281trialhadthewrongintervention27and2werenotrandomizedtrials.25,26Thelastexcludedstudywasaconferenceabstract;thestudydidnotexamineanyofthereview’soutcomesofinterest.24Referencesofthe18remainingstudieswerehandsearchedandnoothereligiblestudieswerefound;thus,1817,18,29–44studieswereincludedinthereview.Althoughalan-guagerestrictionwasnotplacedonthesearch,allincludedtrialswerereportedinEnglish.Reviewershadperfectagreementinselectingthe18studiesusingthestatedeligibilitycriteria.

ANALYSIS

Thecomparisonofinterestforthereviewwasminilaparo-scopiccholecystectomyversusconventionallaparoscopiccholecys-tectomyontheoutcomesofinterestaslisted(Table1).Failureofsurgicaltechniquewastheprimaryoutcomeofinterestwhereasallotheroutcomeswereconsideredsecondary.Beforecommenc-ingthestudy,wedeterminedourapriorihypothesesofheterogeneity(Table2).Subgroupanalyseswereconductedtoexaminetheapriorihypotheses.ReviewManagerVersion5.0(CochraneCollaboration)wasusedtoevaluatethechosenoutcomemeasuresandanalyzedataquantitativelyusingmeta-analytictechniquesanddisplayedwithfor-estplots.Meta-analyseswereplannedforalloutcomesthathaddata,whichincludedameasureofcentraltendencywithameasureofdispersion,whichwereamenableforpooling.

Meta-analysiswasperformedusingarandomeffectsmodel.Becausetheminilaparoscopicinterventionsconsistedof3differentsubtypes,therecouldbebetween-studyvariabilitybecauseofthetechnologyandthuswasreasonabletousearandomeffectsmodel.Toevaluatefailureofsurgicaltechnique,adichotomousoutcome,rel-ativeriskswith95%con denceintervalswereused.Meandifferencewasusedtoevaluatethecontinuousoutcomescosmesis,lengthofop-erativeprocedure,returntoactivity,andqualityoflife.TheI2statisticwasusedtoexamineheterogeneityacrossstudies.21Publicationbiaswasassessedusingafunnelplottoassessthestudiesevaluatingtheprimaryoutcomeoffailureofsurgicaltechnique.20Onceoutcomeswereallevaluated,asummaryof ndingstablewascreatedusingtheGRADEsystem.22,23

RISKOFBIASASSESSMENTOFINCLUDEDSTUDIES

Allselectedstudiesusedaconventionalparallelgroupdesign.Alloperationswereperformedbylaparoscopicsurgeonswithsuf -cientexpertiseinthedescribedproceduressuchthatoutcomesshouldhavebeenoptimalandnolearningshouldhaveoccurredthrough-outthetrials.Ofthe18trials,sequencegenerationwasunclearin1118,30,33–36,39–43trials.Theremainderofthestudies

17,29,31,32,37,38,44

TABLE2.PotentialSourcesofHeterogeneityinStudiesIncludedintheReview

TypesofParticipants1.Ifsurgerywasperformedonanemergencyorelectivebasis

TypesofInterventionsTypesofMinilaparoscopicSurgeryasfollows:1.needlescopicsurgery(4ports,with2 3portsusing

instruments<3mm),2.microlaparoscopicsurgery(4portswith2 3portsusinginstruments≥3mmand<5mm),

3.reducedtrocarsurgery(using<4portswithinstruments≤5mmat1ormoresites).

MethodologyQualityassessmentofstudy(highriskofbiasvs.lowriskofbias)

2.Underlyingreasonpatientrequiredchole-cystectomy

FIGURE1.Summaryofstudyidenti cationandselection.

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usedappropriatemethodstogeneratetherandomizationsequence.Concealmentofallocationwasperformedusingappropriatelysealedenvelopesin4studies32,37,38,44whereas2studies30,39usedenvelopesthatwereinadequatelyconcealed.Concealmentwasunclearintheremainingstudies.17,18,29,31,33–36,40–43Eighttrials17,31,32,35,37,38,40,41dis-cussedblindingofbothpatientsandoutcomeassessorswhereasonly2trials17,37hadblindingofdataanalysts.ThetrialbyTrichak44wasnotblinded.Sixstudies29,35,38,41,43,44usedintentiontotreatanalysisforanalyzingtheirresults.Riskofbiasassessmentofeachmethod-ologicalcomponentwasperformedbyeachreviewer(Fig.2)andaweightedkappawascalculatedtoexamineagreementforeach

com-

ponent(Table3).Anoverallriskofbiasassessmentwasalsoassignedbyeachreviewer(Table4).Weightedkappawascalculatedtoexam-ineagreementbetweenreviewersfortheoverallstudyriskofbiasassessment(Table4).

CHARACTERISTICSOFINCLUDEDSTUDIES

Selectedstudieswerepublishedbetween1999and2007.AllstudieswereconductedinAsia,Europe,orNorthAmerica.Therewerenomulticentertrials.Samplesizefortheincludedstudiesrangedfrom26to200patients.Intotal1539patientswereevaluatedinthe18trialsincluded.Alltrialswereconductedinadultpatients.Themajor-ityoftrialsenrolledpatientswhorequiredelectivecholecystectomy,whereasonly1trial37enrolledbothelectiveandemergencycholecys-tectomypatientsandanothertrial36whichexclusivelyenrolledemer-gencycholecystectomypatients.Detailsofstudypatientsandinter-ventionsareprovidedinTable5.Allminilaparoscopicinterventionswerecomparedtoconventionallaparoscopicsurgery(umbilicus:one10–12-mmport,epigastric:eitherone5-mmorone10–12-mmportandsubcostal:two5-mmports).BaselinecharacteristicsofpatientsinselectedstudiesarepresentedinTable6.

TABLE3.WeightedKappaMeasurementstoAssessAgreementBetweenReviewersinRatingQualityofMethodologyofIncludedTrials

IncompleteFreeofFreeof

AllocationAllocationDataSelectiveOtherGenerationConcealmentBlindingAddressedReportingBiasesκ

1.00

0.93

0.92

0.84

0.60

0.68

TABLE4.OverallRiskofBiasAssessmentforEachStudy

OverallQualityAssessment

Bresadolaetal33Bisgaardetal31Schwenketal43Looketal39Cheahetal35Alponatetal30Bisgaardetal32Schmidtetal42Ainslieetal29Hsieh36

Huangetal37Poonetal40Sarlietal41Trichak44Guptaetal18Novitskyetal17

Kumar,Agrawal,andGupta38Cercietal34κ

UnclearUnclearUnclearHighUnclearHighLowUnclearUnclearUnclearLowUnclearUnclearLowUnclearLowLowUnclear0.92

FIGURE2.Graphicofmethodologyassessment.Blanksquaresindicateunclearriskofbias.

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Overallriskofbiasassessmentwasmadeforeachstudy.Weightedkappa

foragreementbetweenreviewersisshown.Aratingof“high”indicatedthestudyhadanincreasedriskofbiaswhereasaratingof“low”indicatedthestudyhadminimalriskofbias.Studiesreceivedaratingof“unclear”ifreviewerswereunabletodetermineriskofbias.

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TABLE5.StudyCharacteristics

SampleSize

Bresadolaetal33Bisgaardetal31

10226

InclusionCriteriaElectiveASAI-IIElective

ExclusionCriteriaAcutecholecystitisASAIII-IVabdominalwall>10cmERCP1monthbeforechronicpaindiseasesopioidsortranquilizers>1weekbeforehxetoh,drugsAcutecholecystitissevereobesity(BMI>32)ASA>IIIcoagulopathyetohordrugaddictionPatientswhorequiredlaparoscopic

cholangiographyorcommonbileductexploration

Acutecholecystitis

InterventionU :10mm×1,5mm×1U:10mm×1E:2mm×1S:2mm×2

TypeofInterventionReducedtrocarNeedlescopic

Schwenketal43

100Elective

U:5mm×1,E:5mm×1,S:2mm×2U:10mm×1,E:3mm×1,S:3mm×2

Needlescopic

Looketal39

64ElectiveMicrolaparoscopic

Cheahetal35

75Elective

Alponatetal30

68Elective

Bisgaardetal32

60Elective

Schmidtetal42Ainslieetal29

40Elective

Acutebiliarycomplicationsendocrine,metabolic,renalorhepaticdiseasesriskfactorsassociatedwithpneumoperitoneumASAIII-IVage>75ERCP1monthbefore,chronicpaindiseasesonopioidsortranquilizers>1weekbeforespokeforeignlanguagementaldisorderhxetoh,drugsBMI>25essential

HTNacutecholecystitisAcutecholecystitischoledocholithiasispreviousabdominal

surgeryregularopiateuseHemodynamicallyunstablepreviousupperabdominalsurgeryconcurrentdisease,eg,liverabscess,pancreatitisNotclear

U:10mm×1,E:2mm×1,S:2mm×1,3mm×1U:10mm×1,E:2mm×1,S:2mm×2

Needlescopic

Needlescopic

U:10mm×1,E:3.5mm×1,S:3.5mm×2

Microlaparoscopic

40ElectiveASAI-II

U:10mm×1,E:1.7mm×1,S:1.7mm×2U:10mm×1,E:3.3mm×1,S:3.3mm×2U:10mm×1,E:3mm×1,S:3mm×2

Needlescopic

Microlaparoscopic

Hsieh36

69EmergencyMicrolaparoscopic

Huangetal37Poonetal40Sarlietal41

60Electiveandemergency

120135

ElectiveElective

CoagulationdisorderASA>IIIASAIVcirrhosis

pregnancycoagulationdisordersuspectedorprovenmalignancyfailedendoscopictreatmentofbilestonesconcomitantsurgerynotrelatedtocholecystectomy

U:10mm×1,E:2mm×1,S:2mm×2U:1mm×1,E:5mm×1U:3mm×1,E:2mm×1,S:3mm×2

Needlescopic

ReducedtrocarNeedlescopic

(Continued)

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