WO2008028133A2

WO2008028133A2 - Surgical fastener and method of use

Info

Publication number: WO2008028133A2
Application number: PCT/US2007/077392
Authority: WO
Inventors: Charles J. Filipi
Original assignee: Creighton University
Priority date: 2006-09-01
Filing date: 2007-08-31
Publication date: 2008-03-06
Also published as: WO2008028133A3

Abstract

A surgical fastener and applicator for positioning the same are provided for subcuticular incision closure. The fastener 10 is provided with a pair of arcuately shaped arms 12, 14 that extend outwardly from a pair of foot plates 16, 18 that form a hinge 20, which is selectively movable between open and closed positions to draw the arms toward one another. The hinge is secure in the closed position by one of various mechanical fastening mechanisms. The fastener is comprised of a bio-absorbable material to facilitate subcuticular use. The applicator is shaped to position fasteners in subcuticular fashion without impairment of the user's view of the incision.

Description

SURGICAL FASTENER AND METHOD OF USE

RELATED APPLICATION DATA

This application claims the benefit of U.S. Ser. No. 60/841,996 filed September 1, 2006.

BACKGROUND

Various systems and methods have been used by physicians to close wounds and incisions. Sutures, for example, may be employed by different methods according to the circumstances presented and the desired final results. For example, it is often desirable to close incisions with sutures lying completely in the dermis layer in various surgical procedures. Such subcuticular suturing reduces the likelihood of visible scarring, providing the patient with obvious cosmetic benefits. Unfortunately, subcuticular suturing is quite time and labor intensive. Accordingly, in actual practice, physicians frequently elect other suturing methods or use one of various types of surgical fasteners, such as staples or clips.

The use of prior art surgical fasteners provides physicians with a means for quickly closing incisions and wounds. Most such fasteners are deployed from an applicator at an angle that is nearly perpendicular with the incision. However, typical surgical fastener applicators deploy fasteners coaxially with a long axis that extends through the applicators. Therefore, when a physician deploys a staple perpendicular with a tissue surface, the body of the applicator obstructs the physician's view of the incision. Accordingly, the physician must frequently move with respect to the patient, and at times seeming climb on top of the patient, in order to properly view the incision while the applicator is used. Another shortcoming of surgical fasteners is the fact that their use greatly increases the occurrence of visible scarring, rendering this method of incision closure undesirable for many surgical procedures.

The use of many types of sutures and surgical fasteners require the step of removing the same from the patient after the incision has healed. In these instances, the fasteners and sutures may be comprised of various metal or synthetic materials that are not absorbable. The use of different bio-absorbable materials is known in the construction and use of various implants including stents and various orthopedic devices. Implants fabricated from such materials provide significant initial tensile strength and then degrade after several weeks of exposure to human tissue.

Accordingly, what is needed is a novel surgical fastener and applicator for use in subcuticular incision closure. Such a fastener should be bio-absorbable while providing a composition and structural configuration that promote sufficient tensile strength to secure an incision until it has healed. In use, the fastener and applicator should be less time and labor intensive in use than subcuticular suturing.

SUMMARY

This Summary is provided to introduce a selection of concepts in a simplified form that are further described below in the Detailed Description. This Summary is not intended to identify key aspects or essential aspects of the inventive subject matter. Moreover, this Summary is not intended for use as an aid in determining the scope of the invention.

A surgical fastener and applicator are provided for subcuticular closure of incisions. In a preferred embodiment, the fastener is provided with a pair of opposing, accurately shaped arms that extend outwardly from a hinge, which is moveable between open and closed positions. The arms terminate in needle-sharp prongs that enable the fastener to be passed through tissue. The applicator is preferable provided with a handle and a lever that is operatively moveable with respect to the handle. A support member extends downwardly from the handle to support a head unit, which extends outwardly from the support member at an angle in order to dispose a distal end portion of the applicator within the physician's line of sight.

One or more fasteners are stored within the applicator and are deployed from the distal end portion of the head unit. The lever is selectively actuated through multiple stages in the deployment of fasteners. With a fastener partially deployed from the applicator, the physician disposed the arms of the fastener within the opposing sides of the incision. Further actuation of the lever secures the fastener hinge in a closed position and fully deploys the fastener within the incision.

It is therefore a principal object of the present invention is to provide a surgical fastener and method use that provide subcuticular incision closure.

A further object of the present invention is to provide a surgical fastener and method of use that provide subcuticular incision closure that is less time and labor intensive than subcuticular suturing procedures.

Still another object of the present invention is to provide a method of incision closure that positions bio-absorbable fasteners completely with a subcuticular tissue. Yet another object of the present invention is to provide a method of incision closure that utilizes one or more surgical fasteners and method of employing the same that minimize the occurrence of visible scarring.

A further object of the present invention is to provide a hinged surgical fastener for subcuticular incision closure.

Still another object of the present invention is to provide a hinged surgical fastener that is substantially formed from bio-absorbable materials.

Yet another object of the present invention is to provide a surgical fastener applicator that is structurally oriented to permit subcuticular disposition of surgical fasteners in a manner that does not cause the applicator to obstruct the physician's line of sight to the incision.

A further object of the invention is to provide a hinged surgical fastener having various securement mechanisms for securing the surgical fastener in a closed position. These and other objects of the present invention will be apparent after consideration of the Detailed Description and Figures herein.

BRIEF DESCRIPTION OF THE DRAWINGS

Non-limiting and non-exhaustive embodiments of the present invention are described with reference to the following figures, wherein like reference numerals refer to like parts throughout the various views unless otherwise specified. Figure 1 depicts a perspective view of one preferred embodiment of a surgical fastener in an open position;

Figure 2 depicts a perspective view of the surgical fastener of Figure 1 in a closed position;

Figure 3 depicts one manner in which surgical fasteners and an applicator of the present invention may be used to close an incision; and

Figure 4 depicts a perspective view of one embodiment or a surgical fastener applicator that may be used with the surgical fastener depicted in Figures 1 and 2.

Figure 5 depicts a perspective view of a surgical fastener held in the closed position with a retaining clip.

Figure 6 depicts a side view of the surgical fastener of Figure 2.

Figure 7 depicts a top diagrammatic view of surgical fasteners extending from the distal end of a surgical fastener according to another embodiment.

DETAILED DESCRIPTION

Embodiments are described more fully below with reference to the accompanying figures, which form a part hereof and show, by way of illustration, specific exemplary embodiments. These embodiments are disclosed in sufficient detail to enable those skilled in the art to practice the invention. However, embodiments may be implemented in many different forms and should not be construed as being limited to the embodiments set forth herein. The following detailed description is, therefore, not to be taken in a limiting sense.

The fastener 10 is generally provided for fastening tissue. In a preferred embodiment, a fastener 10 is comprised of a first arm 12 and a second arm 14 that extend arcuately, outwardly from a pair of first and second foot plates 16 and 18, which form hinge 20. Optimally, the component parts of the fastener 10 are integrally interconnected with one another. However, various structural connectors may be used to couple the components with one another. Regardless of structural configuration, the fastener should be comprised of a biodegradable (or bio- absorbable) material, known in the surgical arts, including synthetic absorbable polymers, absorbable biopolymers, and the like. Such materials will naturally degrade within the body without the need for mechanical extraction and provide ease of manufacturing, through various molding techniques, while presenting sufficient strength, resiliency and shaping properties.

The first arm 12 and second arm 14 are arcuately shaped in a preferred embodiment, such that the two arms form a generally circular shape when positioned closely adjacent one another. The arms each extend outwardly from hinge 20 and terminate at their distal ends with a distal prong 22 that is sufficiently sharp to penetrate dermal tissue. In certain applications, the arms are smoothly curved and the tips are needle sharp so as to approximate the curved suturing needles that physicians currently use in making subcuticular stitches.

The hinge 20 is moveable between open and closed positions, guiding the first and second arms 12 and 14 through insertion and retention positions, respectively. In a preferred embodiment, the hinge 20 is located posteriorly to prevent any portion of the hinge 20 from protruding above the epidermis once the fastener is secured in place. For example, with reference to the side view of Figure 6, it is contemplated that, due to their different functions, the thickness dimension Tl of the foot plates may be substantially greater than the thickness dimension T2 of the arms, for example 1.5 times or 2 times greater. However, because top surface of the foot plates 16, 18 is generally aligned and in plane with the top surface of the arms 12, 14, the additional thickness of the foot plates extends away from the epidermis. Alternatively, the tops of the foot plates may be offset below the top surface of the arms. While the dimensions of the fastener will vary for the application, it is expected that the length of the foot plates Ll may be about 3 mm and the length of the arms L2 about 10mm.

In a preferred embodiment, the hinge 20 is provided with one or more securement means for securing the hinge 20 in its closed position. Figure 1 and 2 depict one preferred embodiment of securement means, which is simply comprised of an aperture 24 formed in one foot plate and a post 26 that is formed to extend outwardly from the opposing foot plate. The post 26 is shaped and sized to be securable received within the aperture 24. A generally spherical head is depicted at the distal end portion of the post 26. It is contemplated, however, that other shapes would suffice when forming the head so long as the diameter of the resulting shape is sufficient in size, relative to the aperture 24, to resist removal of the post 26 from within the aperture 24.

It is to be appreciated that post 26 and aperture 24 are designed to create a snap fit engagement based on the relative translation of the hinge 20. In the open position (Figure 1), the interior surface 17 of foot plate 16 and the corresponding interior surface of foot plate 18 (not shown) define a hinge angle (e.g. approximately 90°). As the hinge is closed, the hinge angle is reduced and the surfaces are brought into relative apposition, which serves to bring the post into relative engagement with aperture 24. In place of a single centrally located post, plate 16 may be provided with pairs of posts, for example configured to engage upper and lower edges of plate 18. Other known mechanical fastening structures are contemplated for use in securing the hinge 20. For example, Figure 5 illustrates the use of a clip 126 that may be used to secure the foot plates together after the hinge has been closed. Clip 126 is press fit over the exterior surfaces of foot plates after they have been brought together and recesses 124 and engagement of clip 126 in recesses 124 help retain clip in position. Alternatively clip 126 may be hinged to one of the plates and flipped into position at the desired time. Combinations of closure mechanism may also be employed.

The fastener 10 is preferably sized and shaped so that, when the hinge is in an open position, the arms 12 and 14 are positioned to allow sufficient room for the physician to maneuver each of the arms into the corresponding sides of the incision to be closed. However, the respective positioning between the arms 12 and 14 should be such that the closure of the hinge 20 will draw the arms 12 and 14 into sufficient proximity that the incision is adequately closed, despite the tissue's toughness or resiliency.

As depicted, hinge 20 is a living hinge. A living hinge is generally constructed as a thinned or otherwise weakened section of material. For example, a living hinge can be created in a piece of material by scoring a line in the material. It is contemplated that other structural arrangements may be used without deviating from the scope of the invention. However, the living hinge may be preferred due to its relative manufacturing simplicity and durability.

A surgical fastener applicator 28 is provided for deploying and securing one or more fasteners 10 within incisions. The fasteners are deployed from the applicator 28 in the direction indicated by arrow 45. The applicator 28 is generally provided with a handle 30 that is shaped and sized to be comfortably grasped by the physician during use. The handle is oriented along axis 31, and the direction in which the fasteners are ejected is indicated by arrow 45. In a preferred implementation, the handle axis and the fastener ejection direction are parallel lines, though configurations where they define angles of up to up to 15, 30 or 45° are contemplated. A lever 32 is positioned adjacent the handle 30 such that manual actuation may be easily effected by the physician while grasping the handle 30 and articulating the applicator 28. A support arm 34 extends downwardly from the handle 30 to support an elongated head unit 36, which extends outwardly at an angle to the support arm 34. An optional support plate 40 may be positioned along the head unit 36 to provide increased structural support thereto. The support plate 40 may be provided to overhang the edge portions of the head unit 36 to provide a means of directing the upper edge portions of the incision outwardly from the head unit 36. An optional nose member 41 may be provided to extend outwardly from the distal end portion 38 of the applicator 28, below the point of fastener deployment. The nose member 41 will assist in directing the walls of the incision away from the distal end portion 38, providing greater control over the point of insertion of the prongs 22 into the tissue. In this arrangement, the head unit 36 extends into the physician' s line of sight, without obstruction from the tissue associated with the incision, the handle 30 or support arm 34. Accordingly, the physician may use the applicator 28 throughout most common procedures without significantly altering the physician's position with respect to the patient.

The head unit is provided to support a plurality of fasteners 10, which are fed through a linear path extending through the head unit 36 to the distal end portion 38 of the applicator 28. Fasteners 10 are selectively deployed through and opening in the distal end portion 38. Various advancement mechanisms are contemplated that may be operatively coupled with the lever 32, such that initial actuation of the lever 32 will advance the one or more fasteners 10 positioned within the head unit 36 toward the distal end portion 38. For example, an advancement rod and spring combination, commonly found in fastener applicators, may be positioned within the head unit 36 to engage and advance the one or more fasteners 10. Compression jaws may be provided adjacent the distal end portion 38, but in operative communication with the lever 3, to engage and compress the hinge 20 into its closed position with sufficient force to actuate the securement means associated with the hinge 20. Various cam and follower systems, ratchet and tooth arrangements and the like may be used to work in association with the lever 32 to provide the applicator 28 with a two-phase (or more when desired) operation. For example, the cam/ ratchet 42 depicted in Figure 4 may be associated with teeth 44 formed in a portion of the lever 32. A first actuation of the lever 32 relative to the handle 30 will advance the cam/ratchet 42 to a first stage along the teeth 44. The first stage actuates the advancement mechanism associated with the one or more fasteners within the head unit 36 so that a fastener 10 is disposed in a partially deployed position, with the arms 12 and 14 extending at least partially from the distal end portion 38, as in Figure 4. A second actuation of the lever 32 relative to the handle 30 will advance the cam/ratchet 42 to a second state along the teeth 44. The second stage actuates the compression jaws at the distal end portion 38 to compress the hinge 20 into a closed position, which actuates securement means associated with the hinge 20 to secure the same. In a preferred embodiment, the second stage further serves to fully deploy the fastener 10 from the head unit 36.

In use, the distal end portion 38 of the applicator 28 is positioned within the open incision such that the fastener 10, when deployed, will be positioned adjacent a desired location within the severed tissue. Various circumstances, such as the integrity of the surrounding tissue, location of the incision being fastened and the like, may dictate the point of the insertion for the fastener 10. In a preferred embodiment, the fastener is substantially disposed within the dermis, and preferably the arms are disposed entirely within the dermis. However, positioning of a portion of the fastener 10 through subcutaneous tissue is anticipated and may from time to time be desirable.

During a first phase of fastener deployment, the physician or an assistant may use pickups 46 to hold the tissue in a manner that places at least one side of the incision under tension. Alternately, a retractor may be used at the apex of the incision to place the incision under tension. The distal end portion 38 of the applicator 28 is then positioned at a desired location closely adjacent the incision. The applicator lever 32 is actuated to at least partially deploy the arms 12 and 14 of the fastener 10 outwardly and in direction 45 from the distal end portion 38 of the applicator 28. The physician then inserts one of the fastener arms 12 or 14 into the tissue being secured by the pickups 46. The physician or assistant may then cause the pickups 46 to release the tissue and engage the tissue at the opposite side of the incision, placing the same under tension. The second fastener arm is then inserted into the tissue in a manner similar to the first. While use of the pickups 46 to place the tissue in a static position under tensions desirable for directing the fastener arms 12 and 14 through the tissue, the pickups may also be used to position or manipulate the tissue onto the fastener arms 12 and 14 as required. In a second phase of the fastener deployment, a second actuation of the applicator lever 32 causes the compression jaws within the head unit 36 of the applicator 28 to engage and compress the opposing foot plates 16 and 18 of the fastener 10 and force them closely adjacent one another. This action draws the opposing arms 12 and 14 toward one another until the securement means is engaged, securing the fastener 10 in a closed position and closing the severed tissue. Alternatively or in addition, the compression jaws may engage the arms 12 and 14 directly. Completion of the second phase permits the physician to repeat the process with additional fasteners 10, as required. In the end, each of the fasteners 10 are disposed in the dermis and/or the subcutaneous tissue, as the circumstances require. Preferably, the fasteners are left within the subcutaneous tissue to later be absorbed after the incision has healed.

As noted above, during the first phase of deployment, the arms of a fastener are spread outwardly. To increase the effectiveness and ease of use, it is preferably that these arms be spread as wide as possible. In one implementation, depicted schematically in Figure 7, fasteners 10 are provided in a head unit 140 in a generally closed orientation and are spread open out as they are ejected from the distal end of the head unit 140 such that each arm extends beyond the outside edges 142 of the head unit. While applicator 28 is depicted with the head unit 36 is elongated, applicator may be modified such that head unit 36 is shortened. For example the supply of fasteners 10 may be reconfigured to be in the support arm 28, in which case the fasteners would undergo a turn as they are advanced from the supply section to the shortened head unit section, for example as occurs with the subcuticular clips in US Patent No. 5,618,311 to Gryskiewicz (the '311 patent) which is incorporated by reference. Moreover, principals of the present invention may be used to improve upon the subcuticular fastener system described in the '311 patent, for example by modifying the system of the '311 patent such that the handle is oriented along an axis that is close to parallel with the direction in which the clips are ejected.

It is to be appreciated that what has been described includes a novel surgical fastener comprising a bioabsorbable body. The bioabsorbable body includes first and second arcuate arms (e.g. arms 12, 14) extending outwardly from a lockable living hinge (e.g. hinge 20). The arms terminate in needle sharp tips that may be used to penetrate tissue. The hinge may define a hinge axis (e.g. axis 128) and each arm may be substantially disposed in a plane transverse to the hinge axis, which may be a common plane that is generally orthogonal to the hinge axis. The hinge may be configured to have a length along its hinge axis that is greater, for example 1.5 times greater, than a thickness of a midsection of each arm (e.g. Tl greater than T2). The hinge may be provided by first and second foot plates having planar interior facing surfaces that define a hinge angle. The angle decreases as the hinge is moved from an open to a closed position, and the interior facing surfaces are placed in apposition when the hinge is locked in a closed position. It may be locked by snap fit via a snap fit engagement, a clip, or both. What has also been described is a method of securing subcuticular tissue comprising: providing a surgical fastener comprising first and second arcuate arms hinged together; inserting the first arm into a first portion of the dermis while the hinge is in an open position; inserting the second arm into a second portion of the dermis while the hinge is in an open position; closing the hinge; and securing the hinge in the closed position. Closing the hinge may involve reducing the angle between interior facing surfaces to bring the surfaces into apposition. Securing the hinge may include engaging a retaining clip or engaging a snap. The arms may be disposed entirely within the dermis layer, and the first arm may be inserted into the dermis before the second arm is inserted into the dermis. As the arms are inserted, they may be held in extending relationship from the distal end of an applicator and oriented in an applicator direction (e.g. direction 45). The applicator may have a handle defining a handle axis that is within about 45, 30 or 15 degrees of parallel to the applicator direction.

What is also described is a method of securing subcuticular tissue comprising: providing a plurality of surgical fasteners comprising first and second needle sharp arcurate arms in an applicator, the applicator having an distal end defining an application direction and a handle defining a handle axis, wherein the application direction and the handle axis are within about 30 degrees of parallel; extending a fastener from the distal end; inserting the first arm of the extended fastener into a first portion of the dermis; inserting the second arm of the extended fastener into a second portion of the dermis; and bringing the arms together. When the fasteners are extended from the fastener exit, they may be spread such that portions of the arms extend laterally beyond the outer edges of the distal end. What has also been described is a system for subcuticular stapling of body tissue comprising: an applicator having a distal end defining an applicator direction and a handle defining a handle axis wherein the applicator direction and the handle axis are within about 30 degrees of parallel; and a plurality of fasteners comprising first and second arcurate arms each terminating in a needle sharp tip, the fasteners being configured to be retained with their arms in a closed orientation and substantially positioned on a common plane; wherein the fasteners are carried in the fastener so as to be sequentially extended from the distal end of the applicator in the applicator direction with their arms in an open orientation. The arms of a fastener may be extended from the distal end are spread such that portions of the arms extend laterally beyond the corresponding edges of nose. The fastener may be configured such that its arms are rigidly coupled to a hinge that is adapted to be secured in a closed position. The hinge may be comprised of a pair of hinge body portions having interior facing surfaces that define a hinge angle when the arms are the open orientation and are placed in apposition when the arms are in the closed orientation. The fasteners may include a rigid securing member, such as a post, contacting the hinge body portions to hold the hinge in the closed position.

Although the invention has been described in language that is specific to certain structures and methodological steps, it is to be understood that the invention is not necessarily limited to the specific structures and/or steps described. Rather, the specific aspects and steps are merely described as exemplary forms of implementing the invention. As such, many embodiments of the invention can be practiced without departing from the spirit and scope of the invention.

Claims

What is claimed is:

1. A surgical fastener comprising: a bioabsorbable body comprising first and second arcuate arms extending outwardly from a lockable living hinge, wherein each arm terminates in a needle sharp tip.

2. The surgical fastener of claim 1 wherein the hinge defines a hinge axis and each arm is substantially disposed in a plane transverse to the hinge axis.

3. The surgical fastener of claim 2 wherein the arms are substantially disposed in a common plane that is generally orthogonal to the hinge axis.

4. The surgical fastener of any of the preceding claims wherein the hinge has a length along its hinge axis that is greater than a thickness of a midsection of each arm.

5. The surgical fastener of claim 4 wherein the hinge has a length along its hinge axis that is at least 1.5 times greater than a thickness of a midsection of each arm.

6. The surgical fastener of any of the preceding claims wherein the living hinge is provided by first and second foot plates having planar interior facing surfaces that define a hinge angle that decreases as the hinge is moved from an open to a closed position.

7. The surgical fastener of claim 6 wherein the interior facing surfaces are placed in apposition when the hinge is locked in a closed position.

8. The surgical fastener of any of the preceding claims wherein the living hinge is lockable via a snap fit engagement.

9. The surgical fastener of any of the preceding claims wherein the living hinge is lockable via a clip.

10. A method of securing subcuticular tissue comprising: providing a surgical fastener comprising first and second arcuate arms hinged together; inserting the first arm into a first portion of the dermis while the hinge is in an open position; inserting the second arm into a second portion of the dermis while the hinge is in an open position; closing the hinge; and securing the hinge in the closed position.

11. The method of claim 10 wherein closing the hinge includes reducing the angle between interior facing surfaces to bring the surfaces into apposition.

12. The method of claims 10 or 11 wherein securing the hinge includes engaging a retaining clip.

13. The method of claims 10, 11 or 12 wherein securing the hinge includes engaging a snap.

14. The method of claims 10, 11, 12 or 13 wherein the arms are disposed entirely within the dermis layer.

15. The method of claims 10, 11, 12, 13 or 14 wherein the first arm is inserted into the dermis before the second arm is inserted into the dermis.

16. The method of claims 10, 11, 12, 13, 14 or 15 wherein the surgical fastener is comprised of a biosasorbable material.

17. The method of claims 10, 11, 12, 13, 14, 15 or 16 wherein, during the inserting steps, the arms are extending from the distal end of an applicator in an applicator direction, the applicator having a handle defining a handle axis that is within about 45 degrees of parallel to the applicator direction.

18. The method of claim 17 wherein the handle axis is within about 30 degrees of parallel to the applicator direction.

19. The method of claim 17 wherein the handle axis is within about 15 degrees of parallel to the applicator direction.

20. A method of securing subcuticular tissue comprising: providing a plurality of surgical fasteners comprising first and second needle sharp arcurate arms in an applicator, the applicator having a distal end defining an application direction and a handle defining a handle axis, wherein the application direction and the handle axis are within about 30 degrees of parallel; extending a fastener from the distal end; inserting the first arm of the extended fastener into a first portion of the dermis; inserting the second arm of the extended fastener into a second portion of the dermis; and bringing the arms together.

21. The method of claim 20 wherein extending the fastener from the distal end includes spreading the arms of the fastener.

22. The method of claim 21 wherein the arms are spread such that portions of the arms extend laterally beyond the edges of distal end.

23. The method of claim 20, 21 or 22 wherein the fist and second arms are hinged together and bringing the arms together includes closing the hinge.

24. The method of claim 20, 21, 22 or 23 wherein the arms are inserted into the dermis in sequential fashion.

25. The method of claim 24 wherein the arms are inserted entirely within the dermis.

26. The method of claim 25 wherein the surgical fasteners are comprised of a biosasorbable material.

27. A system for subcuticular stapling of body tissue comprising: an applicator having a distal end defining an applicator direction and a handle defining a handle axis wherein the applicator direction and the handle axis are within about 30 degrees of parallel; and a plurality of fasteners comprising first and second arcurate arms each terminating in a needle sharp tip, the fasteners being configured to be retained with their arms in a closed orientation and substantially positioned on a common plane; wherein the fasteners are carried in the fastener so as to be sequentially extended from the applicator distal end in the applicator direction with their arms in an open orientation.

28. The system of claim 27 wherein the arms of a fastener extended from the distal end are spread such that portions of the arms extend laterally beyond the corresponding edges of distal end.

29. The system of claim 26 or 27 wherein the fastener arms are rigidly coupled to a hinge that is adapted to be secured in a closed position.

30. The system of claim 29 wherein the hinge is comprised of a pair of hinge body portions having interior facing surfaces that define a hinge angle when the arms are the open orientation and are placed in apposition when the arms are in the closed orientation.

31. The system of claim 30 further comprising a rigid securing member contacting the hinge body portions to hold the hinge in the closed position.

32. The system of claim 27, 28, 29, 30 or 31 wherein the hinge has a length along its hinge axis that is at least 1.5 times greater than a thickness of a midsection of each arm.

33. The system of claim 27, 28, 29, 30, 31 or 32 wherein the hinge is a living hinge.

34. The system of claim 27, 28, 29, 30, 31, 32 or 33 wherein the fasteners are comprised of bioabsorbable material.

35. The system of claims 27, 28, 29, 30, 31, 32, 33 or 34 wherein the applicator direction and the handle axis are within about 15 degrees of parallel.