The authors describe the development of an ultrafast three-dimensional (3D) optical coherence tomography (OCT) imaging system that provides real-time intraoperative video images of the surgical site to assist surgeons during microsurgical procedures. This system is based on a full-range complex conjugate free Fourier-domain OCT (FD-OCT). The system was built in a CPU-GPU heterogeneous computing architecture capable of video OCT image processing. The system displays at a maximum speed of 10 volume/s for an image volume size of 160 × 80 × 1024(X × Y × Z) pixels. We have used this system to visualize and guide two prototypical microsurgical maneuvers: microvascular anastomosis of the rat femoral artery and ultramicrovascular isolation of the retinal arterioles of the bovine retina. Our preliminary experiments using 3D-OCT-guided microvascular anastomosis showed optimal visualization of the rat femoral artery (diameter<0.8 mm), instruments, and suture material. Real-time intraoperative guidance helped facilitate precise suture placement due to optimized views of the vessel wall during anastomosis. Using the bovine retina as a model system, we have performed "ultra microvascular" feasibility studies by guiding handheld surgical micro-instruments to isolate retinal arterioles (diameter ~0.1 mm). Isolation of the microvessels was confirmed by successfully passing a suture beneath the vessel in the 3D imaging environment.