Abstract: Objective To investigate the relationship between changes in internal carotid artery blood flow and delayed neurocognitive recovery (DNR) after laparoscopic surgery in elderly patients. Methods A total of 175 elderly patients, aged 65-85 years, ASA classification Ⅰ-Ⅲ, who were scheduled for elective laparoscopic surgery were included. Ultrasound measurements of the internal carotid artery were performed at four time points: upon admission (T₀), 10 min after endotracheal intubation under general anesthesia (T₁), 10 min after pneumoperitoneum (T₂), and at the end of surgery (T₃). Internal mean blood-flow velocity (IBVm) and internal blood flow per minute (IBF) were recorded. Cognitive function was assessed using the Mini-Mental State Examination (MMSE) scores 1 day before surgery, and 7, 15, and 30 days after surgery. Patients were divided into two groups based on whether they experienced DNR after surgery. Multivariable logistic regression was used to analyze the risk factors for DNR, and receiver operating characteristic (ROC) curves were plotted to evaluate the predictive performance of independent risk factors. Results A total of 35 patients (20%) developed DNR. Multivariable logistic regression analysis revealed that advanced age, low preoperative MMSE score, longer surgical duration, and decreased IBVm and IBF 10 min after pneumoperitoneum were independent risk factors for DNR in elderly patients undergoing laparoscopic surgery (P<0.05). The cut-off value of IBVm at T₂ was 14.05 cm/s, with an area under the curve (AUC) of 0.835 (0.770-0.901), sensitivity of 0.857, and specificity of 0.721. The cut-off value of IBF at T2 was 209.1 mL/min, with an AUC of 0.841 (0.770-0.912), sensitivity of 0.914, and specificity of 0.679. Conclusions Advanced age, low preoperative MMSE score, long surgical duration, and decreased IBVm and IBF 10 min after pneumoperitoneum are independent risk factors for DNR in elderly patients undergoing laparoscopic gastrointestinal surgery. IBVm and IBF at 10 min after pneumoperitoneum can effectively predict the occurrence of DNR. Elderly laparoscopic surgery patients with IBVm <14.05 cm/s and IBF <209.057 mL/min should be closely monitored for potential DNR.