Abstract:
A fastener including at least an element to be anchored in an anatomical support, at least a stop element relative to a planar prosthetic component to be fixed, and a linking rod is characterised in that the linking rod is rectilinear and the junction zones of the anchoring element and the stop element with the linking rod enable the fastener to adopt: a non-stressed stripping configuration; a maximum stress configuration, doubled up on itself, for example in a tubular configuration by complete insertion of the fastener into a tube, and a minimum stress configuration, wherein the respective directions of the stop element and the anchoring element form between them, for example in the same plane, an angle not greater than 90°.

Description:
FIELD OF THE INVENTION 
   The present invention relates to a fastener for fixing a prosthesis, for example of bioabsorbable material, used for fixing a planar prosthetic component in the human body relative to an anatomical support. It also relates to the device for delivering this fastener. 
   BACKGROUND OF THE INVENTION 
   According to the present invention, the terms used below in the description and the claims have the following meaning:
         “bioabsorbable material” is understood as a material which is decomposed and/or assimilated by and/or in the human or animal body;   “anatomical support” is understood as non-mineralized human or animal support tissues.       

   A prosthesis fastener intended for the repair of a fractured meniscus is known from EP-A-0 847 727. This fastener is made up of at least a first immobilizing bar intended to come into abutment against a meniscus fragment, at least one second immobilizing bar intended to come into abutment against another meniscus fragment, and a curved and elastically deformable linking rod. Said immobilizing bars are connected rigidly to this linking rod in such a way that each of them extends perpendicular in relation to the end of the linking rod to which it is connected. 
   When the fastener is implanted, the linking rod is deformed toward a rectilinear configuration so that it tends to bring the immobilizing bars closer toward one another and thereby ensures retention of the meniscus fragments pressed against one another. 
   The fastener according to the above document is suitable for repairing a meniscus but could not be used to fix a planar prosthetic component, for example a parietal reinforcement, to an anatomical support, in particular an abdominal wall. The reason is that this fastener with an elastically deformable linking rod and with immobilizing bars connected rigidly to this linking rod prohibits any insertion of said first immobilizing bar inside a tissue wall, and said elasticity is not adapted to such an anchoring. 
   Document WO 00/40159 describes a fastener which is also intended to repair a meniscus and which cannot be used to fix a planar prosthetic component to an anatomical support. 
   Document US-C-5 203 864 describes an H-shaped fastener intended to fix a planar prosthetic component to an anatomical support (cf. FIG. 17). This fastener comprises:
         a distal element for anchoring in the anatomical support;   a proximal element for immobilization relative to the prosthetic component; and   a linking rod, which at one end connects to the distal anchoring element, at an intermediate point on the latter, and at the other end connects to the proximal immobilizing element, at an intermediate point on the latter.       

   The main disadvantage of the fastener according to said prior art document and of the device for delivering it is that they do not ensure intimate contact of the prosthetic component with the anatomical support, and intimate contact of this kind is, of course, fundamental for good tissue integration of said prosthetic component. The reason is that the distal anchoring element is deployed at a depth determined by the abutment of the proximal immobilizing element against the prosthetic component. However, given the shape of the fastener, this deployment generates a certain retreat of the distal anchoring element relative to this depth, resulting in the aforementioned lack of intimate contact. Moreover, the presence of the linking rod at the end of the distal anchoring element constitutes an obstacle to insertion of this distal anchoring element and can cause a certain amount of damage at the anchoring site, the consequence of which is to affect not only the depth of implantation of the distal anchoring element but also the strength of the anchoring obtained. This, too, may result in said lack of intimate contact. 
   The present invention aims to provide a solution to this fundamental shortcoming. 
   SUMMARY OF THE INVENTION 
   The fastener to which the invention relates has, in a manner known per se, a single-piece structure which can be obtained by molding of a plastics material, for example a bioabsorbable material, and is composed of at least one element for anchoring in an anatomical support, at least one element for immobilization relative to a planar prosthetic component to be fixed, and a linking rod arranged between a zone of connection to the anchoring element and a zone of connection to the immobilizing element. 
   According to the invention, the linking rod is rectilinear and the zones of connection of the anchoring element and of the immobilizing element to this linking rod allow the fastener to adopt at least three distinct configurations, namely:
         a non-stressed mold-release configuration in which the respective directions of the immobilizing element and of the anchoring element form between them, for example in the same plane comprising the linking rod, an internal angle of at least 90°;   a configuration of maximum stress, doubled back on itself, for example tubular, by complete insertion of said fastener into a tube, in which configuration the anchoring element and the immobilizing element are folded toward the linking rod and toward one another, as it were end-to-end; and   a configuration of minimum stress in which the respective directions of the immobilizing element and of the anchoring element form between them, for example in the same plane, an angle not greater than 90°.       

   The fastener according to the invention permits a surgical approach totally different than that used traditionally. The traditional approach, as is described in document US-C-5 203 884, consists in accessing the posterior face of a tissue wall, from the inside of an anatomical cavity, and in fixing the fastener or fasteners required for holding or fixing the planar prosthetic component. 
   By virtue of the invention, the fastener can be inserted completely into said tube, with said immobilizing element directed toward the distal end of this tube and said anchoring element directed toward the proximal end of this tube. The latter forms a hollow implantation needle which makes it possible, from the direction of the anterior face of the anatomical support, to insert the fastener beyond the prosthetic component situated against the posterior face of this support; a partial extraction of the fastener from the tube makes it possible to release said immobilizing element, which can bear against the prosthetic component, then a return movement of the tube makes it possible to release the rest of the fastener and thus to implant the anchoring element at a depth which ensures intimate contact of the prosthetic component with the anatomical support. 
   Consequently, according to the invention, the device for delivering the fastener comprises said tube and the fastener mentioned above, the fastener being inserted into this tube with said immobilizing element directed toward the distal end of this tube and said anchoring element directed toward the proximal end of this tube; this tube comprises a pointed distal end having a lateral opening, and it is provided with a means for retention of the anchoring element below a threshold force; the lateral opening is dimensioned in such a way as to allow extraction of said immobilizing element from the tube when the fastener is pushed into the tube in the proximal to distal direction, and the retention means is positioned in such a way that it ensures retention of the anchoring element in the tube when the immobilizing element is thus extracted from the tube; said retention means is such that, below said threshold force, it permits the retreat of the fastener with the tube and that, once the immobilizing element is bearing against the prosthetic component and the prosthetic component is pressed against the anatomical support, it requires an increased traction on the tube in order to release the anchoring element, thereby ensuring that this anchoring element has a depth of anchoring sufficient to guarantee that said prosthetic component is pressed sufficiently against said anatomical support. 
   Preferably, said configuration of minimum stress of the fastener corresponds substantially to said mold-release configuration of this fastener. 
   Advantageously, in said configuration of maximum stress, the anchoring element and the immobilizing element are arranged end-to-end, in a continuation of one another, while the linking rod extends parallel to the direction of alignment of the anchoring element and of the immobilizing element, between the two points of connection to, respectively, the anchoring element and immobilizing element. 
   By virtue of the invention, the surgical procedure required for delivery of a fastener consists simply in moving the fastener in its configuration of maximum stress, for example tubular, forward through the tissue wall, then pulling the same fastener back in order to obtain or recover a non-stressed configuration, anchored in the tissue wall. 
   The configuration of a fastener according to the invention also makes it possible to limit the angular stress accumulated upon changing from one configuration to the other at the level of the articulation between the linking rod and, respectively, the immobilizing element and the anchoring element. 

   
     BRIEF DESCRIPTION OF THE DRAWINGS 
     The invention will be better understood from the following description in which reference is made to the attached drawing, in which: 
       FIG. 1  shows an illustrative embodiment of a fastener according to the invention, in the mold-release configuration, 
       FIGS. 2 and 3  show another illustrative embodiment of a fastener according to the invention, respectively in the mold-release configuration and in the configuration of maximum stress, in tubular shape, 
       FIG. 3   b  shows an enlarged cross-sectional view, on the plane IIIb, of the fastener shown in  FIG. 3 , 
       FIG. 4  shows a diagrammatic representation of the method of insertion and delivery of a fastener according to the invention in an anatomical support, 
       FIGS. 5 through 8  relate to another embodiment of a fastener according to the invention,  FIG. 5  showing a front view of the fastener in the configuration of maximum stress,  FIG. 6  showing a plan view of the fastener in the mold-release configuration, and  FIG. 7  showing a side view in the same configuration;  FIG. 8  shows an enlarged view of a detail from  FIG. 7 , 
       FIGS. 9 and 10  show, respectively in the mold-release configuration and in the tubular configuration of maximum stress, another embodiment of a fastener according to the present invention, 
       FIGS. 11 and 12  show, respectively in the mold-release configuration and in the configuration of maximum stress, another embodiment of a fastener according to the present invention, 
       FIG. 13  shows an example of a transcutaneous insertion device according to the invention, for delivering a fastener according to the invention in an anatomical support, 
       FIG. 14  shows an alternative design of an insertion device according to the invention, 
       FIGS. 15 through 18  show another example of a transcutaneous insertion device according to the invention, in different phases of functioning, 
       FIG. 19  shows a detail of the device according to  FIGS. 15 through 18 . 
       FIGS. 20 through 23  show an alternative version of the insertion device shown in  FIGS. 15 through 19 , in different phases of functioning;  FIG. 23   b  shows a cross section, on the line A—A in  FIG. 23 , of a detail of said alternative version. 
   

   DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     FIG. 1  shows, in the mold-release configuration, a fastener  2  comprising an anchoring element  4  and an immobilizing element  6  connected via a linking rod  8 . 
   The latter is arranged between an intermediate point of connection  8   b  to the anchoring element  4  and an intermediate point of connection  8   a  to the immobilizing element  6 . 
   According to  FIG. 2 , again in the mold-release configuration, the intermediate rod  8  has a bulge  8   c  substantially at its center. This bulge  8   c  consists of an excess thickness of material, of limited length relative to the length of the rod  8 , and oriented and disposed only on the top of the core of the rod  8 , and inside the fastener  2  in the tubular configuration of maximum stress shown in  FIG. 3 . As this figure shows, in the tubular configuration the bulge  8   c  fills or occupies the gap left free between the proximal end of the anchoring element and the distal end of the immobilizing element. 
   The fasteners  2  shown in  FIGS. 1 and 2  have a configuration of minimum stress for retention of a prosthetic component, in which configuration the respective directions of the immobilizing element  6  and of the anchoring element  4  are in the same plane comprising the linking rod  8  and between them form, in said plane, an angle not greater than 90 degrees. In the illustrative embodiments shown in  FIGS. 1 and 2 , the fasteners which can be obtained by molding are shown in what is called a mold configuration identical to or closely similar to the configuration of minimum stress described above. 
     FIG. 3  shows a fastener  2  according to the invention in the tubular configuration of maximum stress, as a result of complete insertion of said fastener into a tube (not shown). In this configuration, the anchoring element  4  and the immobilizing element  6  are arranged end-to-end in a continuation of one another, and in particular on either side of the bulge  8   c . In this configuration, the linking rod  8  extends parallel to the direction of alignment of the anchoring element  4  and of the immobilizing element  6 , between the two intermediate points of connection  8   b ,  8   a  to the anchoring element  4  and immobilizing element  6 , respectively. 
   Those ends of the anchoring element  4  and of the immobilizing element  6  which are adjacent in the tubular, stressed configuration compromises two points or bevels  4   a ,  6   a , respectively. 
   In the tubular configuration of maximum stress, as is shown directly by  FIG. 4  (bottom view), or indirectly by  FIG. 3 , the points or bevels  4   a ,  6   a  form an acute angle directed away from the linking rod  8 . 
   In the illustrative embodiment shown in the tubular configuration of maximum stress, in  FIG. 3 , the two adjacent ends of the anchoring element  4  and of the immobilizing element  6  remain at a distance from one another. The anchoring element  4  and the immobilizing element  6  have substantially the same length, while each intermediate point of connection  8   a ,  8   b  is situated substantially at the center of the distal anchoring element  4  or of the immobilizing element  6 . 
   As is shown in particular by  FIGS. 9 through 12 , the connection of the anchoring element  4  and/or of the immobilizing element  6  to the linking rod  8  can be situated at one end or at a point other than the geometric center of said anchoring element and/or said immobilizing element. 
   According to the embodiment shown in  FIG. 3 , two gussets  9  are formed on the linking rod  8  on the outside or opposite the two intermediate points of connection  8   a  and  8   b  to the anchoring element  4  and immobilizing element  6 , respectively. 
   The anchoring element  4  comprises, for example, a pusher head  7  arranged at the proximal end of said rod in the tubular stressed configuration. 
   As is shown in  FIG. 4 , a fastener  2  according to the invention is inserted through a tissue or muscle wall  101  by means of an insertion device, designated generally by reference number  50 , comprising a hollow needle  51 . This needle having the form of a Hubert needle comprises an open and pointed distal end  52 ; more precisely, the tip of the needle  51  is closed by a concave and pointed endpiece  51   a , and it comprises a lateral opening  51   b  opening out in line with the concave endpiece  51   a . The distal portion of the needle  51 , which serves to perforate then pass through the tissue wall and is continuous and solid outside the opening  51   b , on this side of the distal end  52 , makes it possible to contain at least one fastener  2  in its tubular configuration of maximum stress. As is shown by  FIG. 4 , the needle  51  comprises a means  54  of retention (by rearward traction) of the fastener  2 . This means  54  consists of one or more stubs obtained by deformation of material, arresting the retention head provided also for this purpose. This retention means is designed in such a way as to permit relative clearance (between itself and the fastener  2  or its head  7 ), solely by rearward traction on the fastener  2 . 
   The stub or stubs can be arranged relative to the head  7 , or vice versa, so as to orient the staple at an angle relative to its axis, in the tubular configuration. 
   A pusher mandrel  53  is contained inside the needle  50  and is designed to slide freely inside the latter, with distal bearing against the fastener  2  in its tubular configuration of maximum stress, and more precisely its retention head  7 . The pusher mandrel  53  comprises a proximal and external end (not shown in  FIG. 4 ) for directly controlling its forward translation by pushing. 
     FIG. 4  shows an example of the delivery of a fastener according to the invention and more particularly the phases of release of a fastener  2  and fixing of a prosthetic component  100 , which consists principally of a prosthetic tissue, in the surgical procedure employed in the context of the present invention. 
   This fixing is performed on an anatomical support  101  consisting of a tissue or muscle wall. 
   A fastener of this kind is delivered by being passed through the tissue using the transcutaneous insertion device  50 , which is passed through the skin  102  of the patient from outside the body. 
   The fastener  2  thus makes it possible to fix the prosthetic component  100  as is shown at phase D in  FIG. 4 . 
   During a first phase A, described below, the needle  51  passes through the skin  102 , then the tissue wall, and also the prosthetic component  100 , in such a way as to be able to release the immobilizing element  6  beyond and in front of said prosthetic component  100 , by way of the open and pointed distal end  52 , starting from the tubular configuration of maximum stress shown in  FIG. 4A . 
   The method for delivering the fasteners  2  according to the invention is set out for example in  FIG. 4  and can be divided into four phases, A, B, C, and D. 
   During the first phase (phase A), the insertion device allows the needle  51  to be introduced through the skin  102 , the tissue wall  101  and the prosthetic component  100 . The needle  51  passes through the prosthetic component  100  by a distance sufficient to allow the open and pointed distal end  52  to release the immobilizing element  6 , by pushing with the mandrel  53  in the direction of arrow G during phase B, which element moves at least partially away from its stressed, tubular configuration after its release. The pusher mandrel  53  displaces the fastener  2  until the beveled end  6   a  emerges from the needle  51 . 
   According to phase C in  FIG. 4 , the operating surgeon exerts a rearward traction on the insertion device  50  and, consequently, on the needle  51  in the direction of arrow H in order to draw the immobilizing element  6  back against the prosthetic component  100 . From this moment, the fastener  2  changes toward its configuration of minimum stress in which it is relatively open. The immobilizing element  6  thus departs substantially from its stressed, tubular position in such a way as to extend substantially in a direction perpendicular to that of the linking rod  8 . 
   As is shown under C in  FIG. 4 , the beveled shape  6   a  of the end of the immobilizing rod  6  directed toward the prosthetic component  100  makes it possible, by rearward traction of the fastener  2  (of which a part remains inside the needle  51 ) to tilt the rod  6  into a position in which it is flat or parallel to the component  100  or wall  101 . 
   Thereafter, an additional rearward traction exerted on the needle  51  makes it possible to clear the retention means  54 , for example by deformation or by flexion of the pusher head  7  of the fastener  2 , which is then released from the needle  51 . The fastener  2  is then in the relatively open configuration of minimum stress, shown diagrammatically at phase D in  FIG. 4 . In this configuration, the proximal anchoring element  4  also departs reasonably substantially from its position in the mold configuration of the fastener and anchors in the wall  101 . 
   The points or bevels  6   a  and  4   a , respectively, of the immobilizing element  6  and of the anchoring element  4  contribute to excellent insertion of said fastener  2  in any anatomical support in which the proximal rod  4  lodges. 
   It is not necessary for the anchoring element  4  to unfold completely to assume an angular direction perpendicular to that of the linking rod  8  in order to ensure holding or fixing of the prosthetic tissue  100  on the anatomical support. A slight departure of the anchoring element  4  from its relative position in the stressed tubular configuration of the fastener suffices. 
   The presence of the bulge  8   c  makes it possible to lengthen the rod  8  without thereby weakening it with respect to the longitudinal forces which its receives, both during pushing for insertion and delivery of the fastener, in the tubular configuration of maximum stress, and during traction for changing to the configuration of minimum stress for retention of the prosthetic component  100 . 
   The lengthening of the rod  8  makes it possible to increase the depth of anchoring within the thickness of the penetrated tissue wall  101 , which increases the thickness of the biological material, for example tissue, serving for retention of the prosthesis by means of the fastener which has been delivered. 
   The shape used for the bevels  4   a  and  6   a  on the one hand ensures retention of the immobilizing element  6  in the prosthetic component penetrated previously by the fastener  2 , by tilting of said bar, forced by rearward traction of the fastener, and on the other hand promotes the anchoring of the rod  4 , when the rod  8  is under traction, on account of the transverse movement of the prosthetic component  100 , and thus the transverse movement of the immobilizing element  6 . 
   As is shown in  FIG. 4 , part D, the head  7  serves as a means of immobilizing the anchoring in the tissue wall. 
   The fastener according to  FIGS. 5 through 8  differs from that described with reference to  FIG. 1  in that:
         in the tubular configuration of maximum stress, the bevels  4   a  and  6   a  abut against two oblique flanks, respectively, of the bulge  8   c,      the head  7  comprises two peripheral notches or grooves permitting passage of a gas, for example a sterilizing gas, when the corresponding fastener is in the stressed configuration and stored inside a needle  51 .       

   The fastener  2  according to  FIGS. 9 and 10  is characterized on the one hand by an anchoring rod  4  and an immobilizing element  6  with a cross section which decreases in the direction away from the linking rod  8 , and on the other hand by an immobilizing element  6  articulated at its non-free end on the linking rod  8 . 
   The fastener according to  FIGS. 11 and 12  is characterized by several immobilizing bars  6  radiating and several anchoring rods  4  radiating from the two respective ends of the linking rod, the bulge  8   c  having the form of a hub. 
     FIGS. 13 and 14  show two illustrative embodiments of a device for insertion through tissue in accordance with the invention. The transcutaneous insertion device  50  shown in  FIG. 13  comprises the needle  51  having the open and pointed distal end  52 , and an end in which the pusher mandrel  53  is introduced, at the external and proximal end of which pusher mandrel  53  a control member  55  is arranged. 
   The distal penetrating portion of the needle  51  comprises a charge or a plurality of fasteners  2  stored end-to-end, each in their tubular configuration of maximum stress inside the hollow needle  51 . 
   The transcutaneous insertion device  50  also comprises a graduated means  60  of registering the advance of the pusher mandrel  53  inside the needle  51 , thus indicating to the operating surgeon the number of fasteners  2  used. This means  60  makes it possible to count the number of fasteners  2  released when fixing the prosthetic component  100  on the anatomical support, in this case the tissue wall  101 . 
   The retention means  54  is dimensioned in such a way as to retain the pusher head  7  in a manner sufficient to optimally position the immobilizing element  6  against the prosthetic component  100 . 
   The illustrative embodiment of the insertion device shown in  FIG. 14  comprises only a single fastener  2  in the needle  51 . Unlike the retention means designated by  54  in  FIG. 13 , this one designated  154  in  FIG. 14  is made with a rod or a wire connecting said fastener  2  to the pusher mandrel  53 . 
   The insertion devices  50  in  FIGS. 13 and 14  are disposable, containing just one fastener  2  according to the invention in the embodiment according to  FIG. 14  and containing a charge or several fasteners in the embodiment according to  FIG. 13 . 
     FIGS. 15 through 19  show another illustrative embodiment of a device for insertion through tissue in accordance with the invention. The insertion device comprises a handle  70 , at a distal end  71  of which the needle  51  is mounted coaxially. The needle  51  is mounted on the handle  70  with the aid of an engagement piece  72  integral with the needle  51  and engaged at least partially in said control handle  70 . This engagement piece  72  is joined to the distal end  71  of said handle  70  by any known means, in particular by screwing or adhesion. 
   The pusher mandrel  53  passes coaxially and freely through the needle  51 . This pusher mandrel  53  bears at the distal end against a fastener  2  and is arranged at the proximal end freely inside a slide  74  which is mounted freely and in translation, coaxially in the handle  70 . At its proximal end, the mandrel is integral with a core or counter-abutment  90  coaxial to the needle  51  and to the mandrel  53 . 
   Along its axis, the slide  74  comprises a series of axial stops  74   a ,  74   b ,  74   c  which are radially elastic outward and are in a number identical, less one, to the number of fasteners  2  arranged in the penetrating distal portion of the needle  51 . The axial stops  74   a ,  74   b ,  74   c  are spaced apart along the axis of the slide  74  and are separated by a distance equal to the length of a fastener  2  in its tubular stressed configuration, which determines the basic forward travel of the pusher mandrel  53 . 
   A pusher member  80  emerges for a part  80   b  of the handle  70  and is mounted movably in translation coaxially in the latter, its distal end bearing against the end of the slide  74  remote from the needle  51 . The member  80  comprises, inside the handle  70 , a distal face  80   a  opposite the emerging part  80   b  bearing against the slide  74  and against the counter-abutment  90  prior to the first use of the insertion device. 
   This device comprises a means  82  for return of the slide  74  to a rest position, in which the proximal end  74   d  of the slide  74  and the distal face  80   a  of the gripping member  80  bear against one another. The return means  82  is, for example, a spring mounted in the handle  70 , specifically between the distal end of the slide  74 , via a washer  91 , and the distal end  71  of the handle  70 . 
   A non-return means  84  is provided between the distal end  71  of the handle  70  and the pusher mandrel  53 . The non-return means  84  permits the movement of said pusher mandrel  53  forward of said handle  70  and blocks its rearward movement, again relative to said handle. The pusher mandrel  53  is thus blocked in translation in each of its basic advance positions, each corresponding to the complete withdrawal of a fastener  2  from the needle  51 . Each of these basic positions is embodied by each of the distal face  80   a  and the axial stops  74   a ,  74   b ,  74   c  in the position of return of the slide  74 . 
   Each of the stops  74   a  through  74   c  is designed to escape from the counter-abutment  80  when the pusher mandrel  53  is arrested in translation by the non-return means  84 , and when the slide  74  is returned to its return or rest position. For this purpose, each stop  74   a  through  74   c  consists of one or more radially elastic teeth, comprising an inner heel  95  profiled to escape from the counter-abutment  90  when the slide  74  retreats under the action of the spring  82 , and to resist the counter-abutment  90  when the slide  74  advances, and so that the frontal and distal face of each elastic tooth bears against the counter-abutment  90 . 
   When the operating surgeon wishes to extract a fastener  2  from the needle  51  with the transcutaneous insertion device described above, he starts from a position shown in  FIG. 15 . He then presses on the pusher member  80  in order to compress the return means  82  and displace the pusher mandrel  53  by translation so as to expel the immobilizing element  6  from the needle  51 . The travel of the member  80  displaces the pusher mandrel  53  so that the pusher head  7  and the retention means  54  come substantially into contact for the first fastener  2  intended to be withdrawn from the needle  51 . This then gives the arrangement shown in  FIG. 16 . 
   The operating surgeon can then exert a traction on the needle  51  by way of the handle  70  in order to position the fastener  2  against the prosthetic component  100  with the immobilizing element  6 , that is to say against the tissue wall  101 . Exerting a rearward traction this makes it possible to free the pusher head  7  from the retention means  54 . 
   When the operating surgeon then releases the member  80 , the latter returns to its rest position under the action of the return means  82 . The displacement of the slide  74  inside the handle  70  is effected without any relative movement between the pusher mandrel  53  and the handle  70 , this being by virtue of the non-return means  84 . 
   The counter-abutment  90  then comes to lodge in front of the first stop  74   a  provided inside the slide  74 , as is shown successively in  FIGS. 17 and 18 . It is in this new position that the counter-abutment  90  will lodge at the second stop  74   b  and will bear against the first stop  74   a  in the event of a further advance of the pusher member  80 . 
   The insertion device is then in a standby position shown in  FIG. 18 . 
   According to the surgical delivery method described in  FIG. 4 , when the fastener  2  is fully extracted from the needle  51 , the insertion device shown in  FIGS. 15 through 18  is then in an arrangement in which it is possible to extract a second fastener  2 . This is because, when the gripping member  80  is pushed, the slide  74  displaces the pusher mandrel  53  by translation via the first axial stop  74   a  to a second basic position situated in front of and past the position of the second axial stop  74   b  when the slide  74  is at rest. Thus, when the immobilizing element  6  of the second fastener  2  is expelled from the needle  51 , and the pusher head  7  of the second fastener  2  comes into contact with the retention means  54 , the operating surgeon releases the member  80 , which under the effect of a return means  82  places the slide  74  once again in its rest position. The counter-abutment  90  will then lodge in front of the second axial stop  74   b . The complete release of the second fastener  2  can be obtained in this way, and an additional fastener, in this case a third fastener  2 , will then be able to be extracted from the needle  51 , and so on. The insertion device according to the invention and shown in  FIGS. 15 through 19  is not limited to an example permitting the delivery of four fasteners  2 . On the contrary, the corresponding needle  51  can comprise charges with different numbers of fasteners. The size of the insertion device and the diameter of the corresponding needle can also vary without departing from the scope of the present invention. By way of example, the needle  51  can have an internal diameter of 1.6 mm. 
   The device shown in  FIGS. 21 through 23  and  23   b  differs from the device described above in the following ways:
         instead of constituting a separate component of the slide  74 , the pusher member  80  is integral with or forms a single piece with the slide,   to escape from the counter-abutment  90 , when the slide  74  retreats toward its rest position, on the one hand each axial stop  74   a ,  74   b ,  74   c  belonging to the slide  74  is formed by a catch which consists of a through-hole (circular slit for example) in the wall of the hollow slide  74 , and, on the other hand, the counter-abutment  90  is formed by one or more teeth which are able to deform elastically radially outward, such a tooth having a flat surface abutting against the aforementioned catch, in the direction of pushing of the member  80 , and a bevel for sliding against the inner face of the slide  74 , in the opposite direction.